Superomedial Pedicle Breast Reduction Part 4 - Left Breast Operative Procedure | Surgery Spotlight-Surgery Spotlight: Superomedial Pedicle Breast Reduction Part 4

Surgery Spotlight: Superomedial Pedicle Breast Reduction Part 4 - Left Breast Operative Procedure

Video Transcription

So we're performing a breast reduction on this patient. Here's her upper breast border when she was lying down. Sometimes it's really very ill-defined when  they're lying down. I like to do all my determinations when they're standing up because I know exactly where the nipple is going to be at about 10 centimeters  down from the upper breast border and 10 centimeters standing up straight across from the chest midline. So it's a vertical breast reduction using a true  supramedial pedicle. Here's her areolar opening which measures 16 centimeters going all the way around the pigmented part. The vertical opening stays four  centimeters at least above the inframammary fold and this is not a skin operation. So you can take this, check to make sure that you're not taking too  much skin because the key to good wound healing is no tension on the skin and actually no tension on the parenchyma. So a true medial pedicle would start  about four centimeters up, four centimeters down, come around like this. But normally there's an artery that we can usually doppler from here  and I want to include this part here because it gives me a dual axial blood supply. The veins are just under the dermis. They don't travel with the  arteries. We see them when we deeply utilize the arteries are just about a centimeter deep in the subcutaneous tissue. The only artery that goes  through the parenchyma and supply the nipple is at the fourth interspace, makes sense, just above the fifth rib. Just medial to breast meridian supplies an  inferior pedicle. The inferior flap of rubella when you're doing a mastopexy and it goes straight up through parenchyma to nipple. All of the other  blood supply, mostly internal mammary, go in through the subcutaneous tissue up to the nipple. There's a superficial branch of the lateral thoracic that does the  same which would supply a lateral pedicle although sometimes a lateral it comes a bit lower than a normal lateral pedicle would be. So I like this dual  axial blood supply with a true supra medial pedicle and the inferior border of my medial pedicle, whether it's true medial, true supra medial, then becomes my  medial pillar and so I don't get a hollow inferior breast with this. I get a nice elegant curve on the table. So this patient has very little fat. She's  obviously not overweight. I will do some infiltration of the areas where I do a bit of liposuction. So if she's a very fatty patient I would put tumescent  fluid in the pre-axillary area, lateral chest wall, but in this case I'll just put a little bit in the lateral area. I used to infiltrate the incisions but  then I would catch these veins and cause little hematomas. So I don't infiltrate my incisions anymore. I just infiltrate a little bit out here. So I usually start  with my incisions first. I know where I want to have them. I'm not going to really change them. Sometimes I might adjust the areolar opening if it's not a  true circle at the end, but I know where I want to make my incisions and then we'll do the deeper epithelializing.  Coker please. And cookie cutter. So with the cookie cutter I don't think it matters what the opening is so much as what the skin opening is because the  real skin will stretch. So this is 45 millimeters which is it's a good size but it's not this that makes the difference. It's the skin opening. The  areola will stretch to fit the skin opening and if it's too large then you have to add permanent sutures which can cause problems with the areola  stretching over the permanent suture. So I prefer to match them. Everybody has different ways of doing their deeper epithelializing. I like this strip method. It doesn't matter.  So the true supramedial pedicle has been deeper epithelialized. A true medial pedicle would come here. So we've include that supposed artery from the second  interspace as long well as the third interspace. I have actually left a strip of skin here which I actually often don't do. We want to leave a little bit  of a platform here so that the nipple doesn't retract. I'm doing this mostly for demonstration. I like to use the cutting coterie. I don't think it  matters whether you use a knife or a cutting coterie but I will completely go around my pedicle and carry it as a full thickness pedicle down the chest wall.  The first, and you can see quite easily, the first things I hit are the veins and then I hit that artery.  So we now have basically a full thickness supramedial pedicle. Full thickness is not for blood supply because the arteries are in that first  centimeter down. But there is a nerve that comes, obviously the lateral fourth intercostal nerve that comes up and we've cut the superficial branch but the  deep branch goes under, turns up around breast meridian. So a full thickness pedicle might help with sensation and there's obviously medial nerves as  well. My experience, a medial supramedial pedicle gets 85% of patients get normal to near normal sensation. Superior pedicle only 67% and surprisingly a  lateral pedicle only 76%. So medial pedicle tends to have the same sensation not shown by me but by others as an inferior pedicle. So full thickness  medial pedicle directly down to breast meridian and now I'm going to remove that inferior wedge of breast tissue. Again hitting the veins to start with  because they're in just underneath the dermis and then as I go a little bit deeper I will hit some of the arteries.  So when I'm cutting out that inferior wedge of breast tissue there's the areolar opening. As I come up here I will often come across the superficial  branch of the lateral thoracic nerve or artery sorry which would supply an inferior pedicle and there it is right there. So if you are making a lateral  pedicle you have to come down sometimes it's even lower than that so you have to make sure that you're low enough. So basically I'm in the process of removing  this inferior wedge of inferior breast tissue. I've cut it away from the supramedial pedicle and coming down here there's my areolar opening I've made  direct straight down because I want at least a two centimeter lateral pillar here. Now as I come across this I'll probably cut across the artery and vein  that would supply an inferior pedicle and it comes just above the fifth rib in the fourth interspace and would supply a inferior pedicle.  Sometimes it's not a very dominant artery which is why I think sometimes it doesn't we end up with some nipple necrosis problems. It didn't bleed  profusely but I did put some of my infiltration into there but this is where that artery comes. So I've removed that inferior wedge of breast tissue  it's not about how much skin is removed so I've removed that inferior wedge we have a full thickness true supramedial pedicle. Lateral pillar is obviously a  lot thicker than two centimeters I want two centimeters in the end but where is the excess breast tissue? Well inferior wedge but out here laterally so this is  where I'm going to take that extra lateral breast tissue so if I can have a coker please. So I want a two centimeter lateral pillar and I want to take excess  breast tissue out underneath that lateral flap. Because she's 20 years old this is not tissue that you can suction easily you have to actually physically  cut it out. So I'm coming along with the two centimeter thick lateral pillar and I'm going to remove that excess breast tissue underneath that lateral flap.  So after cutting down leaving a two centimeter thick lateral pillar I've removed some of that lateral breast tissue. When you look down in here  there's still some lateral breast tissue in her case again this is not fat this is thick white breast tissue you have to physically carve that out. You want to  leave just a wise pattern not extra beyond it so in an older person you can suction that extra beyond it. In her case being young I actually physically need  to cut out some more of that lateral breast tissue. What I want to do is leave behind a nice wise pattern of parenchyma with no tension on the parenchyma and no  tension on the skin. So I will keep going at this bit by bit until I get a nice comfortable wise pattern of parenchyma left behind and no breast tissue beyond  that wise pattern outline.  So I've now basically cleared out that extra breast tissue out underneath that lateral flap but my pillar is about seven centimeters long but I still have  excess breast tissue out here laterally. Again if it's not thick white stuff you can suction it but in her case I actually physically need to cut this extra breast tissue out.  True Supramedial pedicle dual axial blood supply full thickness drowned to chest wall lateral pillar about two centimeters clearing out that lateral  excess breast tissue where it is so the excess was inferior lateral that's removed. When this comes together you can see that it leaves a nice shape with a  nice wise pattern of parenchyma. I have cleared out tissue underneath you want to leave fat on here because you don't want scar contracture happening but you  want this part pretty well cleared out and whether you do it the way I do with the Cochlear and the excision cautery or cut it that way it doesn't matter what  you want to do is remove the breast tissue below inferior to the wise pattern leaving the wise pattern behind. So in order to assess my final shape  size etc I usually put my first stitch in the bottom of the areola so I'm through the dermis there you don't need to undermine it to put that  suture in and then where the areola opening was here on the other side and this is just a good first stitch to figure out what you're doing. No tension  so this is not a tension operation we're not using the skin as a brassiere. So once I put that first areola suture in you can get a sense of what the breast  is going to be like. The nipple tends to fit nicely into position and if it didn't if it was thick breast tissue which sometimes happens or that true  super medial pedicle is blocking it a bit then debulk it in fairly that's not or deeply that's not where the blood supply is. So when I pulled that up into  position you can see that the lateral pillar and the medial pillar start to meet. The medial pillar having been the inferior border of the medial pedicle  now becomes the medial pillar. Your medial pillar sutures don't start down here and they don't start at the inframammary fold they start about seven  centimeters down at this point about halfway up that skin opening. So the best way to figure out how to put the pillars together is to take your pedicle  pull up like this and that pull up maneuver tells you exactly where the bottom of your pillars are. So you can keep that up you can go in and grab the  lateral pillar here you don't need a deep stitch this isn't about putting great big deep tension stitches it's just about getting medial pillar to  lateral pillar to sit together long enough that they heal together. So that gives you your first pillar suture. Every time you put another pillar suture in  grab the top of the pedicle and pull it up and it will help you align your pillars. So again pull up you don't need more than three or four sutures in here  because again you're just trying to get pillar to pillar apposition for healing and in her case I'll probably just put one more suture up there and then start  the deep dermal sutures.  So in here going right through grabbing some of that dermis it doesn't matter. You can pull up if you need to in this case I just want to come underneath so  that I actually get that tissue here  and basically that's all I need. So what I have here you can see is a wise pattern cleared out in caudal to the wise pattern and now I'll just close the  dermis and do a little bit of liposuction just for shaping and tailoring. So I talk about the wise pattern if you were to do an inverted T  and for your pedicle you'd be coming along here and taking out at least some of that skin out here. That's what I mean by the wise pattern but I want to leave  the wise pattern of parenchyma behind. I have removed a lot of this parenchyma in here but I'm going to finally tailor it out with liposuction. So even though the  pillar might be 7 centimeters and the skin might be about 10 centimeters it will tuck up underneath. So I'm going to do a little bit of liposuction on this  part here again just for shaping.  Sometimes people will have some quite thick pre-axillary fullness that they want to get rid of which of course is they can't get rid of  it it's normal but we can reduce it. So I go up underneath the breast tissue and do a little bit of liposuction under here. It frankly is always better to  underdo this area than overdo it because you don't want to leave irregular dents. Then I will come out and do a little more laterally you can see that's extra that needs to go.  So I've performed a liposuction out here so that this is thinned out here I've left that wise pattern this has been cleared out not so much that you're  going to get scar contracture between the skin and the chest wall you want to leave a nice fat that slides around. Don't suture the pucker down to the  chest wall because you'll end up with a long-term problem with a hole and an indentation here let it slide let it find its own position. I will put four  sutures around the dermis of the areola and then do a subcuticular suture. Do not gather that vertical line you don't need to do that and I'll show you how it  tucks up under in a minute. So I've now done the subcuticular around the areola and vertically you want to make sure that the areola is a pretty much a  circle at the end. I have not gathered that vertical incision if you gather it you'll get pleats and weird things at the bottom it doesn't shorten the  incision by gathering it it always either lengthens out or leaves these pleats. So the pillars go down to about here what happens with the breast is  this tucks in underneath. Now how do you know whether to take that pucker out or not the breast doesn't come down like this as it heals the best way to do it  is to actually lift the breast up and if when you lift it up and away from the chest wall like that you can get that pucker to tuck in then you don't need to  remove it. So although the pillar goes down here at the pucker the skin will tuck up underneath so you will get a nice shape in the end. So true  supramedial pedicle we've removed almost 400 grams on both on this side and a little bit of liposuction just for tailoring.

Video Summary

The video transcript outlines a surgical procedure for breast reduction using a vertical reduction with a true supramedial pedicle. The surgeon emphasizes the importance of making determinations with the patient standing for precise nipple placement. The procedure involves measuring and marking the areolar opening, as well as ensuring no tension on the skin or parenchyma to promote good wound healing. The transcript details the method of creating a dual axial blood supply, which ensures good blood flow and sensation to the nipple. The surgeon discusses specific techniques like liposuction and removing lateral excess breast tissue, tailoring each patient's needs based on their body type and amount of breast tissue. The process concludes with strategically placing sutures to maintain breast shape and ensure proper healing without tension, ultimately resulting in a natural and aesthetically pleasing contour.

Asset Caption

In this video, Elizabeth Hall-Findlay, MD, demonstrates a superomedial pedicle breast reduction procedure on the left breast of a 20-year-old patient. At the outset, as the patient is prone on the operating table, she retraces the markings previously made while the patient was standing up, and outlines the topography of the veins, arteries and nerves in relation to the planned incisions. She discusses her infiltration strategy, performs the initial incisions and de-epithelization and discusses the different pedicle options before removing the inferior wedge of breast tissue. She completes the operation and uses liposuction to refine the result. Surgeon Elizabeth Hall-Findlay, MD This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Breast

Elizabeth Hall-Findlay MD; Member

Content Codes-VI. (COSM) Plastic Surgery of the Breast

Content Codes-VI. E. (COSM) Aesthetic and Functional Problems of the Breast

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

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

breast reduction

supramedial pedicle

nipple placement

blood supply

liposuction