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Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction

Mammoplasty

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DOI: 10.4172/2161-1076.1000321

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 Surgery: Current Research Fahmy et al., Surgery Curr Res 2019, 8:3
DOI: 10.4172/2161-1076.1000321

Research Article Open Access

Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction

Mammoplasty
Karim Fahmy, Tamer Salama*, Ahmed Aly, Tarek Youssef and Ahmed Gamal
Department of General Surgery, Ain Shams University, Egypt
*Corresponding author: Tamer Salama, Department of General Surgery, Ain Shams University, Egypt, Tel: 201113623458; E-mail: drtamer1981@hotmail.com
Received date: November 5, 2018; Accepted date: February 18, 2019; Published date: February 25, 2019
Copyright: © 2019 Salama T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution and reproduction in any medium, provided the original author and source are credited.

Abstract

Background: Reduction mammoplasty is a challenging combination of aesthetic and functional plastic surgery. It
is a technique that provides a safe and predictable result with NAC preservation. The end result should be judged on
volume, scar pattern, shape, symmetry, and nipple position with projection. Though the ideal normal breast does not
exist, the ideal operated breast should satisfy certain morphologic criteria. Despite diversity of procedures, there is
no consensus about the ideal technique for reduction mammoplasty.

Aim: To compare the clinical and the aesthetic outcome of the superomedial pedicle and the inferior pedicle
techniques in reduction mammoplasty for females complaining of symptomatic breast hypertrophy.

Methods: 24 patients with huge symptomatic breasts at department of General Surgery, Ain-shams University
hospitals from Jan 2017 to September 2018 were divided into two groups; Group (A) Patients underwent reduction
mammoplasty using superomedial pedicle technique and Group (B) Patients offered inferior pedicle technique. Both
groups were compared as regards aesthetic, surgical outcome and relief of complaint.

Results: 10 patients in group A suffered from pain and pra-srap groove opposite to 9 in group B. In group A and
B 11 patients out of 12 in each group had unaccepted body shape with social embarrassment. Mean BMI was 38.72
and 36.96 in group A and B respectively. The mean weight of excised tissue in our study was 1151.6 grams in group
A and 1167.1 grams in group B. There was relief of pain in 100% of group A, 83.3% of group B. Pra strap groove
diminished in 100% patients. optimum patient satisfaction occurred in 100% of group A and 83.3% of group B.
Regarding the Desired size and shape of the breast, in group A; 11 patients (91.7%) gave Very good, 1 patient
(8.3%) gave good while no patient gave poor (0%), on the other hand 3 patients (25%) in group B gave very good, 7
(58.3%) good and 2 (16.7) poor. 4 patients in group B (33.3%) had boxy breast deformity, while no patient (0%) in
group A had such complication.

Conclusion: Both superomedial and inferior pedicle techniques in reduction mammoplasty are safe, feasible and
effective however boxy breast deformity.

Keywords Mammoplasty; Plastic surgery; Surgery while creating a stable, aesthetically pleasing, and durable breast shape
with minimal resultant scars [3].
Introduction Ribeiro introduced a dermal-lipoglandular flap based on the
Female breast hypertrophy is an abnormal enlargement of the breast inferior aspect of the breast mound and used this tissue to "auto
tissue in excess of the normal proportion. This condition may be augment" the breast after tissue resection [4]. Courtiss and Goldwyn
caused by gland hypertrophy, excessive fatty tissue, or a combination of identified the mammoplasty technique in which the inferior pedicle
both. It varies in severity from mild (<300 g) to moderate (300-800 g) contains the nipple-areola and the closure is accomplished by
to severe (>800 g) [1]. Symptomatic breast hypertrophy can have conversion of the keyhole incision into an inverted T incision [5].
negative physical and psychosocial manifestations such as persistent The inferior pedicle techniques have been successfully perpetuated
neck and shoulder pain, painful shoulder grooving from brassiere through plastic surgery training programs as safe techniques to reduce
straps, chronic rash of the inframammary fold, backache, and and reshape the breast with adequate vascularity, sensation, and
peripheral neuropathies. As a consequence, it is a medical condition position of the NAC. Another added advantage is preservation of
that requires therapeutic management. Since non operative treatments breast's lactation potential as continuity of the breast parenchyma is
don’t give long lasting results therefore it is most often managed by not disturbed however bottoming out remains one of the most
reduction mammoplasty [2]. Long-standing debate over the optimal potential drawbacks which can be avoided keeping the bulk of the
technique for breast reduction represents the difficulty plastic surgeons tissue centrally located under the nipple-areolar complex with minimal
have in surgically creating the ideal breast. The primary surgical tissue along the lower border of the pedicle. Also Resection in several
objectives remain to safely move a sensate and vascularly intact NAC areas of the breast makes this procedure more complex [6].

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Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 2 of 10

The superomedial pedicle was introduced by Orlando and Guthrie axis of the breast was then marked 10 to 14 cm from the abdominal
in 1975 as a modification of the superior pedicle technique [7]. Its midline below the level of the inframammary crease. To mark the
design was intended to shorten pedicle length while broadening the upper limit of the new areola, an index finger was placed in the
pedicle as a means to enhance blood flow and maintain innervation of inframammary crease and a mark then made on the forward
the NAC. In this technique, the NAC is transposed on a superomedial projection of the index finger onto the anterior surface of the breast.
de-epithelialized pedicle which contains a thin layer of subcutaneous Another way to locate the new nipple site was 2-3 cm below the mid-
tissue to protect the dermal blood supply. This pedicle is based on the arm point. Lateral and medial markings were determined next, for the
full extent of the medial skin flap patterned after Wise and the entire medial one the breast was put upward and laterally and a line was
new nipple position except for a small lateral portion. The nipple is made projecting the previously made vertical axis onto the breast.
laterally rotated into place instead of folding the pedicle upwards in. Similarly, the lateral line was drawn by pushing the breast upward and
Subsequent reports by Hauben and Finger et al. verified the safety of medially. the key hole-pattern centered over the new nipple mark was
this procedure which is advantageous in providing a substantial used to draw the wise-pattern and its ring diameter are about 38-45
amount of superomedial fullness and better superior blood supply mm Diameter of the new areola (diameter between 38 and 45 mm)
owing to its shorter length compared to an inferiorly based pedicle [8]. was drawn between indentation marks of the metallic ring with its
In the present study, we evaluated superomedial pedicle technique and central hole applied just over the nipple. The superomedial pedicle is
the inferior pedicle technique; both techniques were done on Wise- marked from the center of the new areola position passing around
pattern skin resection. The aesthetic and surgical evaluation was NAC and ends either or near the bottom of medial limb of inverted V.
assessed in both groups. The flap length is between 6-11 cm.

Patients and Methods

Prior to the study, IRB approval was obtained from the Medical
Research Ethics Committee of the Faculty of Medicine in Ain Shams
University, and written informed consent was obtained from all
patients before enrolment. Our study is prospective study that was
conducted on 24 patients with huge symptomatic breasts of cup (D-G)
at department of General surgery Ain-shams University hospitals from
Jan 2017 to September 2018. Patients were divided into two groups;
Group (A) underwent the superior medial pedicle technique and
Group (B) in which inferior pedicle technique was performed. Nature
and possible consequences of the clinical study were explained to all
patients. Most of patients were women after childbearing: who are
interested in relief from symptoms of heavy breasts and correction of
the post-lactation ptosis and post-menopausal patients require breast
reduction to relieve the symptoms related to large and heavy breasts.
All patients included were subjected to full preoperative assessment
including history taking, clinical examination. Preoperative breast
sonography for patients <35 years and sonomammography for patients Figure 1: Preoperative marking of the superomedial technique.
>35 years to exclude any other pathology of the breast. Postoperatively,
all patients were followed up weekly for one month then monthly for 6
months for assessment of the viability of flaps, the vascularity and Surgical technique: The inverted V area was de-epithelialized
sensitivity of the NAC and the aesthetic outcome regarding the desired including the outer rim of the old areola outside the new areolar
size, weight, shape and the symmetry of both breasts according to the marking. IMC incision was deepened till the deep fascia and the breast
breast measurements. was lifted off the pectoral fascia up to the nipple-areola level. Then the
breast was lifted upwards perpendicular to the chest wall and the lower
Outcome portion of the breast was excised (Figure 2 and 3). A wedge of lateral
tissue and a tangential disk of deep central tissue were resected.
The primary end goal was to assess the aesthetic outcome of each Superomedial pedicle was undermined at 2 cm thickness and made
technique from the patient point of view. Secondary end goal was to progressively thicker towards the base. The pedicle was freed laterally
assess the degree of relief hypertrophy symptoms e.g. neck and by an incision at the lateral edge of the V all the way upwards NAC
shoulder pain, rash of the inframammary fold. then laterally rotated easily into their new place. Breasts checked for
symmetry. Temporary clips were used to approximate flaps and to the
Superomedial flap technique new IMC. The proposed areolar position was prepared by drawing a
circle and the skin was excised in full thickness to accommodate for
Preoperative markings were done with the patient in an upright
the transposed areola. Final closure proceeded by 4-0 Vicryl
position. Midline was drawn from the supra-sternal notch down onto
intracuticular sutures of the areola and 4-0 subcutaneous Vicryl sutures
the umbilicus (Figure 1). The breast meridian from the mid-clavicular
and subcuticular 3-0 Prolene. Drains were removed after 48 hours
point to the nipple. The infra-mammary line was marked. The vertical
(Figure 4).

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Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 3 of 10

of the new areola was done. The base was marked 5 cm lateral and 5
cm medial from breast meridian. The outlines of the pedicle were
drawn, extending beyond (NAC) (Figure 5).

Figure 5: Preoperative marking for inferior pedicle breast reduction.

Surgical technique: De-epithelialization of the pedicle was done.

Medial, lateral and superior breast skin flaps were elevated with
beveling downwards towards the chest wall until the loose areolar
tissue layer overlying the pectoral fascia is reached and is preserved.
Skin flaps should not be less than 2 cm. in thickness. The breast tissue
Figure 2: Lateral view of the superormedial pedicle right breast. was removed in a horseshoe shaped pattern around the inferior pedicle
with an attempt made to perform most tissue resection laterally and
the least amount of resection is done medially. The pedicle was shaped
by inserting 5-7 absorbable 3/0 sutures which were tied in solid knots
over large loose loops designed to just bring the breast tissue together
in a kissing fashion without strangling the blood supply. Then the
breast was sutured to the chest wall superomedially by few loose
stitches. 11- The skin edges were brought together. The periareolar
incision and the vertical limb were closed. The breast was supported by
elastic adhesive tapes leaving a trap door dressing on the nipple and
areola to allow their inspection during follow up (Figure 6).

Figure 3: Lateral view of the superormedial pedicle left breast.

Figure 6: Intraoperative photo showing the pedicle.

Results

Patient characteristics
Figure 4: Immediate post-operative photo. The age of patients in our study ranged from 33 to 50 years in group
A with a mean age of 40.25 years and ranged from 30 to 48 years in
group B with a mean age of 38.83 years. 9 patients of group A had
positive family history while 8 patients of group B had positive family
Inferior pedicle technique
history. Regarding the complaint; all patients suffered from large size of
Midline was marked by connecting the suprasternal notch to the breasts. 10 patients in group A suffered from pain and pra-srap groove
umbilicus. The inframammary fold was marked between two points. opposite to 9 in group B. In group A and B 11 patients out of 12 in each
The medial point is 3-4 cm lateral to sternal border and hidden under group said they have unaccepted body shape and complained from
the medial fold of the breast. The lateral point of the inframammary social embarrassment. The mean BMI in our patients was 38.72 in
fold is drawn 1 cm medial to its preoperative position. Breast meridian group A and 36.96 in group B. All patients underwent general
is outlined. The new level of the nipple was marked as a point in breast anesthesia with no statistically significant differences between both
meridian lying 20-22 cm from the suprasternal notch. The areola was groups in anesthetic outcome or operative time. The mean weight of
marked. The upper limit of the new areola was above the nipple point excised tissue in our study was 1151.6 grams in group A and 1167.1
by a distance equal to the radius of the new areola (22 mm). Marking gram in group B (Table 1 and 2).

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Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 4 of 10

Group N Mean SD t P Value Sig.

Age Group A 12 40.25 5.56 0.59 0.561 NS

Group B 12 38.83 6.19

Children number Group A 12 2.67 1.07 0.32 0.752 NS

Group B 12 2.50 1.45

Clinical examination .

Height Group A 12 157.67 4.96 -0.17 0.870 NS

Group B 12 158.00 4.94

Weight Group A 12 94.83 11.91 0.55 0.590 NS

Group B 12 92.42 9.62

Group A 12 38.72 4.19 1.14 0.266 NS

BMI Group B 12 36.96 3.31

Weight of excised tissue Group A 12 1151.67 268.29 -0.15 0.884 NS

Group B 12 1167.17 244.21

Table 1: Patient characteristics.

Group A Group B Total X2 P Value Sig.

Patient history
(n=12) (n=12) (n=24)

Negative 3(25.0%) 4(33.3%) 7(29.2%) 0.20 1.0 NS

Family history
Positive 9(75.0%) 8(66.7%) 17(70.8%)

Pt complaint

No 0 0 0 - - -
Large size
Yes 12(100%) 12(100%) 12(100%)

No 2(16.7%) 3(25.0%) 5(20.8%) 0.25 0.50 NS

Pain
Yes 10(83.3%) 9(75.0%) 19(79.2%)

No 2(16.7%) 3(25.0%) 5(20.8%) 0.25 0.50 NS

Pra-strap groove
Yes 10(83.3%) 9(75.0%) 19(79.2%)

No 1(8.3%) 1(8.3%) 2(8.3%) 0.0 1.0 NS

Unacceptable body shape
Yes 11(91.7%) 11(91.7%) 22(91.7%)

No 1(8.3%) 1(8.3%) 2(8.3%) 0.0 1.0 NS

Social embarrassment
Yes 11(91.7%) 11(91.7%) 22(91.7%)

Table 2: Comparison between the two groups regards family history and complains.

Post-operative assessment dehiscence occurred in 1 patient in each of the two groups. Seven
patients (29%) complained of decreased NAC in the early
There were statistically highly significant difference regards desired postoperative period. However, after 6 months, only 1 (4.1%) patient in
size and shape and no statistically significant difference between the Group A still had decreased NAC sensation opposite to patients
two groups regards asymmetry and relief of complaint. 1 patient out of (16.7%) in group B. 4 patients in group B (33.3%) had Poxy breast
24 (4.2%) had post-operative hematoma. Regarding Seroma 2 patients deformity, while no patient (0%) in group A had such complication.
(16.7%) in group A had mild seroma while in group B 3 patients (25%) NAC Necrosis occurred in none of our patients (0%). Scar hypertrophy
had mild seroma. wound infection did not occur, however wound occurred in only 1 patient in group B (8.3%). And finally Dog ears

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Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 5 of 10

occurred in 1 patient in group A (8.3%) and 2 patients in group B hematoma, seroma, wound dehiscence, NAC malposition, scar
(16.7%) (Figure 7). There were no statistically significant differences; hypertrophy and dog ears. There was statistically significant difference
between the two groups regards assessment of complication for between two studied groups regards boxy breast deformity (Table 3).

Figure 7: Bar chart representing comparison between the two studied groups regards assessment of complication.

Relief of patient complaint Group A Group B Total X2 P Value Sig.

(n=12) (n=12) (n=24)

Large size Not satisfied 0 2(16.7%) 2(8.3%) 2.18 0.487 NS

Satisfied 12(100%) 10(83.3%) 22(91.7%)

Pain Present 0 2(16.7%) 2(8.3%) 2.18 0.487 NS

Relieved 12(100%) 10(83.3%) 22(91.7%)

Pre-strap groove No - - -

Diminished 12(100%) 12(100%) 24(100%)

Unacceptable body shape Not accepted 0 2(16.7%) 2(8.3%) 2.18 0.487 NS

Accepted 12(100%) 10(83.3%) 22(91.7%)

Social embarrassment Embarrassed 0 2(16.7%) 2(8.3%) 2.18 0.487 NS

Confident 12(100%) 10(83.3%) 22(91.7%)

Aesthetic outcome .

Poor 0 2(16.7%) 2(8.3%) 10.53 0.003 HS

Desired size good 1(8.3%) 7(58.3%) 8(33.3%)

Very good 11(91.7%) 3(25.0%) 14(58.3%)

Poor 0 2(16.7%) 2(8.3%) 10.53 0.003 HS

Shape good 1(8.3%) 7(58.3%) 8(33.3%)

Very good 11(91.7%) 3(25.0%) 14(58.3%)

No 11(91.7%) 10(83.3%) 21(87.5%) 0.38 0.50 NS

Asymmetry
Yes 1(8.3%) 2(16.7%) 3(12.5%)

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Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

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Complications

Hematoma No 11(91.7%) 12(100%) 23(95.8%) 1.04 0.50 NS

Yes 1(8.3%) 0 1(4.2%)

Seroma No 10(83.3%) 9(75.0%) 19(79.2%) 0.25 0.50 NS

Yes 2(16.7%) 3(25.0%) 5(20.8%)

Wound dehiscence No 11(91.7%) 11(91.7%) 22(91.7%) 0 1.0 NS

Yes 1(8.3%) 1(8.3%) 2(8.3%)

Wound infection No 12(100%) 12(100%) 24(100%) - - -

Yes

NAC- Sensation No 11(91.7%) 10(83.3%) 21(87.5%) 0.38 0.50 NS

Yes 1(8.3%) 2(16.7%) 3(12.5%)

NAC-necrosis No 12(100%) 12(100%) 24(100%) - - -

Yes

Scar hypertrophy No 12(100%) 11(91.7%) 23(95.8%) 1.04 0.50 NS

Yes 0 1(8.3%) 1(4.2%)

Dog ears No 11(91.7%) 10(83.3%) 21(87.5%) 0.38 0.50 NS

Yes 1(8.3%) 2(16.7%) 3(12.5%)

Boxy breast deformity No 12(100%) 8(66.7%) 20(83.3%) 4.80 0.047 S

Yes 0 4(33.3%) 4(16.7%)

Fisher's exact Chi-Square test

Table 3: Post-operative assessment.

Discussion Although, the inferior pedicle Wise-pattern reduction has been, and
still is, the most widely used technique in the United States. Many
Breast hypertrophy has been and will always a challenge to breast surgeons prefer the Wise-pattern technique in larger breasts because
surgeons, after the evolution of the breast reduction surgery, the there will be no excess, redundant skin at the IMF that must be
process took a long time for both, the patients as well as for the observed for some time, and may never completely resolve. Although it
surgeons to have well and acceptable results. Nahai mentioned that any has its benefits, this technique also has some down sides. By using the
operation on the female breast is to be considered an aesthetic inferior pedicle, you are relying on the skin envelope to hold up the
procedure not only augmentation and mastopexy, but also reduction weight of the inferior breast tissue and shape the breast. Many times,
and reconstruction [9]. Multiplicity of reduction techniques indicates the surgeon creates a short, tight lower pole of the breast during the
that no technique is perfect and no single technique suits all cases. reduction to help prevent early bottoming-out. This yields a breast
Criticism of procedures includes the loss of long term projection, shape that is unnatural in the early postoperative period. Despite this,
quality and length of the scars and development of squaring. Several the breast usually continues to bottom-out over time, and the long-
techniques have appeared over years, but yet till now, there is no single term result is usually a breast with pseudo ptosis in the end [11].
technique that fulfills all the criteria approached by the critics.
Reduction mammoplasty by the inferior pedicle technique was applied The age of patients in our study ranged from 33 to 50 years in group
frequently. This technique developed in mid-1970s, by Curtiss, A with a mean age of 40.25 years and ranged from 30 to 48 years in
Georgiade, Goldwyn, Ribiero and Robbins, for the purpose to increase group B with a mean age of 38.83 years. Regarding the marital status of
vascularity [10]. These operations when combined with "Wise pattern" the patients 100% was married. The mean BMI in our patients was
are reliable, reproducible and have become very popular because it is 38.72 in group A and 36.96 in group B. Roehl et al. in a retrospective
applied to the breasts in different sizes. This technique although study of 179 reduction mammoplasty patients, concluded that breast
reliable and easy to apply, it is linked to an increase "bottoming-out" reduction is a safe operation regardless of their BMI or size of
deformity, consisting of boxy-shaped breast and decrease upper pole reduction and with no increase in the rate of postoperative
fullness. complications in the obese or morbid obese patients or in
gigantomastia patients [12]. On the other hand, obesity was reported

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Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 7 of 10

by many studies to increase complications following reduction months while in group B, 3patients (25%) had mild seroma one of
mammoplasty (Figure 8). them required ultrasound guided needle aspiration. We suppose that
these results were due to the patient’s incompliance regarding wearing
the compressive breast garment as all those patients who came with
seroma reported giving up wearing the compressive pra less than 3
weeks post operatively in addition to early returning to daily work.
NAC viability and safety of superomedial pedicle is attributed to its
broad pedicle (superiorly and medially base) which encompass the
perforator of internal thoracic artery [17] (Figure 10 and 11).

Figure 8: Anterior view before (left side) and after (right side)
reduction mammoplasty.

The mean weight of excised tissue in our study was 1151.6 grams in
group A and 1167.1 grams in group B. Said et al. reported resection
weight ranging from 800 to 3900 grams per breast, using the
superomedial pedicle technique [13]. Georgiade et al. reported safe
resection volumes up to 2500 grams per breast in inferior pedicle Wise
pattern reduction mammoplasty [14]. Hunter and Ceydell studied 122 Figure 10: Viable NAC post superior medial technique.
patients undergoing inferior pedicle reduction mammoplasty during 3
years’ period and divided the patients into two groups according to the
average quantity of tissue resection (< 1000 gm. and > 1000 gm.) [15].
They compared the two groups as regard the rate of complications and
found no statistically significant difference between the two groups.
Therefore, they concluded that reduction mammoplasty can be safely
performed with resection volumes more than 1000 grams without
added complications (Figure 9).

Figure 11: Postoperative hematoma post superomedial pedicle

technique resolved spontaneously.

Zambacos & Mandrekas studied the rate of complications in the

Figure 9: Excised breast tissue weight 950 gm using inferior pedicle inferior pedicle reduction mammoplasty and reported an incidence of
technique (LT) and weight 1200 gm using superior medial pedicle 0.4% of NAC necrosis and 1.5% of fat necrosis [18]. They stated that
technique (RT). the incidence of NAC necrosis depends on the length and the base
width of the pedicle more than any other variable while fat necrosis
occurs due to poor blood supply to areas of fat due to combination of
T- Junction dehiscence occurred in 22 breasts (18%) in Landau et al. infection, bad surgical technique and smoking. Al-Shahat et al.
study, while in our study 2 cases (8.3%) developed unilateral reported the performance of inferior pedicle reduction mammoplasty
postoperative T-Junction dehiscence [16]. Hauben described in 30 cases with 0% incidence of NAC necrosis [19]. They attributed
commencement of the key suturing starting laterally so that the lateral this to the preservation of the horizontal breast septum that was
excess skin is pushed medially to relieve tension at tripod point [17]. described by Wuringer et al. and so improving the NAC vascularity
He advised not to place a suture at this point at all. It seems this [20]. They also reported preservation of NAC sensitivity. O'Dey et al. in
dehiscence in our cases is due to moderate tension at this point. In our an anatomical microdissection study stated that vascular variability
Study only 1 patient out of 24 (4.2%) had post-operative hematoma and overlap may account for the remarkable safety of diverse NAC-
which resolved on follow up completely with no permanent effect on bearing pedicles, even though pedicle thickness influences vascular
the aesthetic outcome. reliability [21]. They observed that lateral and medial approaches
Regarding Seroma in our study, 2 patients (16.7%) in group A had however, clearly show vascular advantages over that which can be
mild seroma which resolved spontaneously and completely within 3 observed in inferior and superior pedicles.

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2161-1076
Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 8 of 10

Wound infection in our study did not occur, however wound improvement in the difficulty in daily work and in the embarrassing
dehiscence occurred in 1 patient of each group (8.3%) (Figure 12). Scar comments from others in our study occurred in 100% of group A and
hypertrophy occurred in only one patient in group B (4.2% of all 83.3% of group B. Only 2 patients of the 24 (8.3%) in our study (group
patients) in our study. Antony et al. compared the superomedial B) still complaining of unaccepted body shape, while 100% of patients
pedicle vertical scar with traditional inferior pedicle Wise-pattern and in group A have accepted body shape post operatively. Schnur et al. in
reported wound infection rate of 2% in the former and 1% in the latter their outcome study found that 85.1% of the women who underwent
[22] (Figure 13). reduction mammoplasty experienced relief of symptoms beyond their
expectations [24]. Of the remaining patients, 10.1% had as much relief
as expected, and only 2.4% were worse than expected. Ninety-seven
percent of patients rated their quality of life as improved
postoperatively, and 97.3% would definitely or probably make the same
decision with regard to the procedure.
Regarding the Desired size and shape of the breast from the patient
point of view, in group A; 11 patients (91.7%) gave Very good, 1
patient (8.3%) gave good while no patient gave poor (0%), on the other
hand 3 patients (25%) in group B gave Very good, 7 (58.3%) good and
2 (16.7) poor. Ciloglu et al. in their study found very high satisfaction
degree among their patients treated by superomedial technique
regarding postoperative breast shape and volume, scar, nipple
sensation as well as reduction shoulder, neck and back pain with
Figure 12: Wound dehiscence post Inferior pedicle. possibility of lactation [25] (Figure 14).

Figure 13: Scar hypertrophy occurred 3 months postoperative using

inferior pedicle.

Women with larger breasts have lower sensation of NAC

preoperatively. This is explained by two factors. First, the increased
surface area of the large breast with respect to the constant number of Figure 14: Superormedial technique before and 6 months after.
nerve fibers in the intercostal nerve that innervate the breast. Second, Regarding the desired size this 2 patients gave (Very good) score.
the increased weight and increased pull by gravity that result in
traction injury to the intercostal nerves [22]. Seven patients (29%) in
our study complained of decreased NAC sensation in the early Antony et al. in their matched cohort study found that the
postoperative period. However, after 6 months, only 1 (4.1%) patient superomedial pedicle produces high levels of patient satisfaction in
(In Group B) still had decreased NAC sensation. In Said et al. series, patients, particularly in those who wish to maintain a significant post-
nipple sensation was preserved in 41 breasts (82%) out of 60 breasts surgical breast volume [21]. Additionally, Hall-Findlay suggests that
[13]; he tested sensation by touch and 2-point discrimination while we patients seeking smaller reductions may have cosmetic expectations
assessed nipple sensation by touch only. This sensory preservation of beyond what is feasible in small-volume reduction mammoplasty [6].
nipple is due to sensory supply of nipple-areola complex come equally Guthrie et al. compared 33 patients seeking reduction mammoplasty
from medial and lateral aspect through anterior and lateral cutaneous for macromastia with 22 control patients with macromastia and they
branch of 4th intercostal respectively additional nerve supply come observed that they experienced greater physical and sexual difficulties
from the anterior cutaneous branches of 2nd to 5th intercostal nerves but similar social difficulties as compared to the control group [26].
and the lateral cutaneous branches of the 3rd to 5th intercostal nerve, They also observed that patients were more anxious and depressed and
this would explain the preservation of sensation despite probable had poor body image and self-esteem. Chahraoui et al. reported
severance of fourth lateral cutaneous branch or so called nerve to the improvements in physical, social and sexual life in 95%, 55.5% and
nipple. Mofid et al. found no significant difference between the medial 75% of patients respectively [28].
and the inferior pedicle reduction mammoplasty regarding Regarding the symmetry of both breasts after surgery, 1 patient in
postoperative NAC sensation [23]. group A (8.3%) complained of asymmetry while 2 patients in group B
In our study, there was relief of pain in 100% of group A, 83.3% of (16.7) had this complaint. DeFazio et al. reported incidence of
group B. Pra strap groove diminished in 100% of our patients. The postoperative asymmetry of 8% in 241 cases who underwent inferior

Surgery Curr Res, an open access journal Volume 8 • Issue 3 • 1000321

2161-1076
Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 9 of 10

pedicel reduction mammoplasty [28]. Kreithen et al. reported 0% because it is applied to the breasts in different sizes. This technique
incidence of significant postoperative asymmetry in their cases although reliable, easy to apply, with good sensation, it is linked to an
operated upon by the same technique [29]. One cannot assess increase "bottoming-out" deformity, and "boxy shape" is one of the
asymmetry before at least three months pass postoperatively and disadvantages of this reduction technique (Figure 17 and 18).
fortunately asymmetry is usually due to excess tissues (which can be
removed in another sitting by liposuction or excision), not due to
excess resection (which may need prosthesis).
In our study, 4 patients in group B (33.3%) had Poxy breast
deformity, while no patient (0%) in group A had such complication.
Çiloglu et al. in their study of 50 patients, they compared the aesthetic
result of Wise pattern superomedial pedicle and inferior pedicle breast
reduction techniques [25] (Figure 15 and 16).

Figure 17: Inferior pedicle technique before and 6 months after

surgery. Regarding the desired size this patient gave (very good)
score.

Figure 15: Poxy breast deformity post inferior pedicle.

Figure 18: Inferior pedicle technique before and 3 months

postoperative.

They found that statistically significant differences regarding the

upper pole fullness ratio and bottoming-out deformity between the
two groups. They concluded that the superomedial pedicle combined
with "Wise pattern" skin incision provide upper pole fullness and
reduce the formation of "boxy-type" breast. Brown et al. in their study
on 79 patients who underwent superomedial pedicle Wise-pattern
breast reductions [30]. They found that combining the two techniques
and using the superomedial pedicle with a Wise-pattern skin resection
can take advantage of the benefits of each, while eliminating some of
the downsides. In our study there were no statistically significant
differences between both groups in anesthetic outcome or operative
time.

Conclusion
Superomedial technique is a safe operation in which nipple
preservation rates approach 100% with high rates of nipple sensation.
Long lasting conical breast projection is achievable in all cases. It has
low complication rate, predictable and rapid resection pattern, the
shape of the reduced breast can be consistently created with
aesthetically desirable upper and medial fullness while minimizing the
Figure 16: Inferior pedicle breast reduction before and 6 months
risk of bottoming out.
postoperative.
Disclosure
They found that the inferior pedicle technique when combined with This research did not receive any specific grant from funding
"Wise pattern" are reliable; reproducible and has become very popular agencies in the public, commercial, or not-for-profit sectors.

Surgery Curr Res, an open access journal Volume 8 • Issue 3 • 1000321

2161-1076
Citation: Fahmy K, Salama T, Aly A, Youssef T, Gamal A (2019) Superomedial Pedicle vs. Inferior Pedicle Techniques in Reduction
Mammoplasty. Surgery Curr Res 8: 321. doi:10.4172/2161-1076.1000321

Page 10 of 10

Conflict of Interest Statement 16. Landau AG, Hudson DA (2008) Choosing the superomedial pedicle for
reduction mammoplasty in gigantomastia. Plast Reconstr Surg 121:
The authors have no conflict of interest to disclose. 735-739.
17. Finger RE, Vasquez B, Drew GS, Given KS (1999) Superomedial pedicle
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