Superomedial Pedicle Breast Reduction Part 2 - Patient Markings | Surgery Spotlight-Surgery Spotlight: Superomedial Pedicle Breast Reduction Part 2

Surgery Spotlight: Superomedial Pedicle Breast Reduction Part 2 - Patient Markings

Video Transcription

So this is a 20 year old patient who is having a breast reduction. She's five feet five and a half inches tall, weighs 120 pounds and just can't find a broader fit.  She says she's probably about a triple D but obviously she's actually much bigger than that. So for marking the most important landmark is the upper breast  border. This will not change. Where is the upper breast border? I'm not going to pay attention right now to the inframammary fold. The upper breast border is always  at that pre-axillary to breast indentation and crosses here because the breast will not go higher than that. We can get a better angle but we cannot  move the footprint up higher on the on the chest wall. If you want to move the footprint up you have to add something, fat or an implant, but with a breast  reduction mastopexy upper breast border doesn't change. So it seems like an ill-defined landmark but if you pull the breast up like this and fold it up  look where it folds. So you can see that that is the upper breast border. There's obviously a bit of breast tissue up above that but as a landmark the upper  breast border right where that indentation is is the most stable point. So now I'm going to mark her suprasternal notch, her chest midline. I'm  ignoring the inframammary fold. Now for breast meridian you want to mark the breast meridian where it should be not necessarily where it is. So I'm going to  ignore where her nipple position is. I'm going to start midpoint which is usually about seven centimeters. It doesn't matter up here. What matters is where you  mark it down here. So I'm going to draw the breast meridian where I want it to be which is just a bit medial to her existing nipple position. If you don't  mark it where it should be you'll get off off base. So marking her breast meridian and the existing nipple is going to end up with much too lateralized  nipples. An ideal nipple position is on an average C-cup breast is about 10 centimeters down from the upper breast border and about 10 centimeters drawn  straight from the chest midline. So I'm just checking my lines because I'm videotaping I'm on an angle. Okay so where do we want the new nipple  positioned? At the most projecting part of the resulting breast which her most projecting parts down here. But here is about where we want the new nipple  position. She wants to be about a D-cup whatever that is. So that's my first mark just assessing it. This one's still a little bit higher than the other one.  She's pretty symmetrical in volume. Nine and a half centimeters down from the upper breast border. Ten centimeters from the upper breast border. Let's see what  it is from supersternal notch. 22 and 22 and a half. So I'm actually going to move this down just a little bit. We want these to be pretty symmetrical. Excuse my  head. Now if I measure straight from that new nipple position to chest midline it's 10 centimeters. So if you start measuring the nice breasts you see, 10  and 10 on a C-cup breast is an ideal C to D-cup breast is an ideal nipple position. So you notice I haven't done really much in the way of measurements.  I'm now adding two centimeters up for my new top of the areola. So that's nipple position. Now I'll draw my areola freehand. You can use a template.  A large paper clip is 16 centimeters in length which would give you a five centimeter diameter areola. All I want, and I'm not going mosque shape out on  the side, I want to get around the areola pigmentation obviously, but I want to have in the end a circle. So that's what you're aiming for. So this kind of  opening, getting around the pigmented part as much as you need to, then checking to make sure that what you're leaving behind is a circle is what's  important. So now I'm going to check to make sure those are symmetrical and obviously they're not. And I'm moving this there. Check again. So that's good.  Now what I want to leave behind is the Y's pattern. I don't want to take the Y's pattern out in skin. I want to leave behind the Y's pattern in parenchyma. So  I'm leaving this like this. You okay? Oh yeah I'm good. Good. And like this and like this. So again if you visualize it, that's the Y's pattern. So again check to make sure  that we're symmetrical because what we want to do is, it's not what we take out being symmetrical, it's what we leave behind that's symmetrical. So from here now  what I do is, you could do the Marchak-Lasur-Lasus maneuver where you rotate the breast like that and you match up chest meridian, breast meridian,  and chest meridian again. That's a good way to do it. Or this way. But what I find is if I just take my thumb, bring this up, remember this is not a skin operation.  This is a parenchymal reshaping operation. And you want to leave about four centimeters above the inframammary fold. Again take your thumb, lift up, join  these above the inframammary fold there. About four centimeters up the fold for a couple of reasons. You close an ellipse, it's going to get longer. Her inframammary  fold will rise up even if you don't try to make it rise up. So keep it high. So you can see chest midline, upper breast border being the most important landmark,  breast meridian where it should be, not necessarily where it is, areola opening to match about 16 centimeters which makes a 5 centimeter diameter areola.  Remove the Y's pattern. This is not a skin operation so we don't want the skin closure to be tight. So the way to check to make sure you're removing the right  amount, just pinch it and don't take too much. Now, pedicle next. You could do a superior pedicle. I actually find a true medially based pedicle easier to inset  because a medially based pedicle, the inferior border of the pedicle becomes my medial pillar, rotates nicely into position instead of having to fold it up and  crunch it. But a true medial pedicle would be about four centimeters up the areola opening, about four centimeters down, and you would do this. The problem with a  medial pedicle is that we miss the absolute best blood supply which comes down from the second enderspace. We include the artery from the third enderspace. But  this artery that comes down, descending artery from a delta pectoral flap, is awesome. So we should keep it. It makes insetting sometimes a little bit harder  but because the blood supply is in the subcutaneous tissue just deep to the dermis, veins being in the dermis, just under the dermis, arteries being about a  centimeter deep. If we have any trouble insetting the pedicle, debulk it deep. That's not where the blood supply is. There's blood supply going to the  parenchyma but apart from the artery and vein that comes over the fourth enderspace, the only artery vascular supplies that really goes through the  parenchyma to the nipple is that one from the fourth enderspace. Everything else is in the subcutaneous tissue going around. So we can debulk parenchyma quite safely.  So true supramedial pedicle, I'm going to add this so I include that artery from the second enderspace. And as you see this rotate up, inferior border of my  medial pedicle becomes my medial pillar. Now the final thing here is where is the inframammary fold? Well there's the inframammary fold down about here. And  this one on this side is clearly just a little bit higher but not much. So her folds are about there. Am I going to put her new nipple position at her  inframammary fold? No because it already is at the inframammary fold. So although the inframammary fold works as a landmark in about 80% of patients, there  are a lot of patients it doesn't work on. And those of us have been practiced for a while can kind of just say oh yeah well we're going to put it here. But for  people who are new in practice and you need a little bit more of a guidance, upper breast border is absolutely perfect guideline. It's not going to go  higher. So if you know it's not going to go higher, put your nipple right where you can visualize it and then you can visualize that this is what we're going  to be removing. So what do I remove with this procedure? I remove the breast where it's in excess and then the skin pattern is separate. Where's the excess? Inferior  and lateral. Because she's 20, this is going to be solid glandular breast tissue which if she were 50, I could contour this nicely with liposuction. But  because she's 20, this has to be carefully carved out otherwise you're going to get a melon sideways look with these breast reductions. You need to  remove the extra where it is. Inferior and lateral and you'll see that during the surgery. So the markings, the measurements, the only measurement I  really like is 10 and 10 and then 2 centimeters up, 16 centimeters. The rest is not important.

Video Summary

The video transcript discusses a breast reduction procedure for a 20-year-old patient who is 5'5.5" tall and weighs 120 pounds. Key highlights include the importance of determining the upper breast border, which is a critical and stable landmark that helps guide the surgery. The surgeon discusses the process of marking out the breast meridian, nipple position, and areola, emphasizing that the procedure is more about reshaping the breast tissue (parenchyma) rather than managing the skin. The transcript details technical aspects, such as pedicle choice and how the inframammary fold functions in planning the surgery.

Asset Caption

In this video, Elizabeth Hall-Findlay, MD, demonstrates how she marks a patient for breast reduction surgery to achieve the operative goals while maintaining breast symmetry. She discusses the importance of and how to determine the upper breast border, shows how to mark the breast meridian, and how to measure and mark for an appropriate new nipple position before discussing blood supply and marking the inframmamary fold.

Surgeon Elizabeth Hall-Findlay, MD This product is not certified for CME.

Keywords

Surgical Videos

surgery spotlight

Breast

Elizabeth Hall-Findlay MD; Memben

breast reduction

breast meridian

inframmamary fold

nipple position

Content Codes-VI.E.3.a. (COSM) Diagnosis

Content Codes-VI.E.3 (COSM) Mammary ptosis

Content Codes-VI.E.1.b. (COSM)Surgical therapy

Content Codes-VI.E.2.(COSM) Mammary hypoplasia

Content Codes-VI.E.1. (COSM)Mammary hypertrophy

Content Codes-VI.E.3.b. (COSM) Surgical techniques

Content Codes-VI.E.2.a. (COSM) Techniques for correction

breast reduction

surgery planning

breast reshaping

inframammary fold

pedicle choice