Superomedial Pedicle Breast Reduction Part 5 - Right Breast Operative Procedure | Surgery Spotlight-Surgery Spotlight: Superomedial Pedicle Breast Reduction Part 5

Surgery Spotlight: Superomedial Pedicle Breast Reduction Part 5 - Right Breast Operative Procedure

Video Transcription

So we performed a supramedial vertical breast reduction on the left side, about 400 grams removed. So the plan is to do the same on this side. Here's the areolar opening.  Upper breast border was marked about here, that's the important landmark. Then the skin excision is not the important part, it's the parenchymal excision.  So a vertical approach, there's inframammary fold, it's about four centimeters above the inframammary fold.  You can check to make sure that you're not taking too much skin by doing the pinch test because this is not a skin brassiere operation.  A true medial pedicle comes around there, about four centimeters above the areolar opening, about four centimeters below.  But in her case, and we saw with the Doppler, there's a good artery there, so we want a dual axial arterial blood supply, and to do that for safety, I am including this part,  which is a true supramedial pedicle. If you follow this out, this is what you would be doing with a, about five centimeters down,  coming out with an inverted T. I'm going to remove the inverted T of parenchyma, but not skin. And she's only 20, so she's got really good quality skin. But where's the excess?  Inferior and lateral, and that's where I'm going to remove the tissue. If you want a good, long-lasting result that holds up with time and doesn't rely on skin  to hold it up, for example, remove the extra where it is, leave the extra in the Y's pattern,  still attach the top half of the breast, and remove the bottom part, which is susceptible to gravity.  So I do infiltration, not in the incisions anymore, because it would damage the veins. I put a little bit in the areas where I'm going to perform a bit of liposuction.  If she were heavy, then the areas where I'm going to do the liposuction, then I would put in tumescent-type fluid, just to help control some of the bleeding from the liposuction.  Blood supply to the breast. You have the artery and vein that comes up at the fourth interspace, just above the fifth  rib, just medial to breast meridian, that supplies an inferior pedicle and the inferior flap that Ribeiro described for mastopexy. That's artery and venae cometantes.  That's really the only artery that goes through the parenchyma to get to the nipple.  The rest of the arteries, veins being just underneath the dermis, you see them with de-epithelializing.  The other arteries are in the subcutaneous tissue, mostly from internal mammary system, come up in the subcutaneous tissue around the parenchyma, not through it.  Obviously there's blood vessels to the parenchyma, but for the nipple, it comes up around it. So mostly internal mammary, superficial branch of lateral thoracic.  So I start with incisions in the skin itself. I know where I'm making my incisions. I don't adjust them later because I think my best chance to get a good nipple position  is doing that marking about 10 centimeters down from the upper breast border when she's standing.  I might adjust the areola a little bit at the end of the procedure to make sure that it's a good circle, but other than that, I don't usually change my incisions.  So the cookie cutter is not the important measurement. This is 45 millimeters. This areola will stretch to fit the skin opening.  So this skin opening is 16 centimeters, which matches a five centimeter diameter areola. If you make it too large, the areola will stretch and then you might want to consider  a permanent suture. I don't really like permanent sutures because the areola often will stretch over top of it.  So the best way to get a good result is to match the skin opening to the areola so that you get the diameter you want. So I'm doing a true supramedial pedicle here.  I tend to use the strip method of doing the epithelializing. It doesn't really matter. And when you do this, you can start seeing the veins just under the dermis.  They don't travel with the arteries, but they are just underneath the dermis. Blood supply to most of the breast nipple is superficial in the subcutaneous tissue.  So I've deepithelialized the true supramedial pedicle with the dual axial blood supply,  and then I'm going to carry this pedicle directly down to chest wall, leaving it as a full thickness pedicle.  As I go down through this tissue, I hit the veins first, just underneath the dermis, and then as I go a little further down, I hit the arteries.  So we have a full thickness supramedial pedicle down toward chest wall. I'm leaving it full thickness for innervation, not for blood supply because you've got the  lateral fourth intercostal nerve. Obviously we've cut the superficial branch, but there's a deep branch that goes along  pectoralis fascia and at the midline, mid meridian, goes up into the breast. So a full thickness pedicle might help sensation.  Medial pedicle, 85% of patients recover normal to near normal sensation. Superior pedicle, only 67%, which makes sense because there's really not that much innervation that way.  And lateral pedicle, only 76%. So medial pedicle, inferior pedicle, both have about an 85% recovery of normal to near normal sensation.  So medial pedicle sensation is actually pretty good. Now what I'm going to do is remove that inferior wedge of breast tissue.  Remove the breast tissue where it is in excess, inferiorly and laterally. So I will first remove that inferior wedge of breast tissue.  Again, I hit the veins first, and just underneath the dermis, and then I will end up hitting the arteries a little deeper down.  So I'm removing the inferior wedge of breast tissue, leaving a lateral pillar. So as I cut down the lateral pillar, I will cut underneath the lateral flap afterwards.  But as I cut down the lateral pillar, I will hit the superficial branch of the lateral thoracic artery, which was probably what I just hit right there.  And then as I go along and underneath here, we'll often see the artery and vein that supply an inferior pedicle as it comes up above the fifth rib, and that's probably what was  leading right there, part of it. So true supramedial pedicle, full thickness. I've removed that inferior wedge of breast tissue. I came up around the areola.  You can deepithelia, you can take that off, but you want to leave a little bit of a wedge of breast tissue here so you don't get retraction of the areola. But I've removed that.  It's not about removing skin. It's about removing the parenchyma. The skin is just going to be allowed to re-drape around the new shape.  Now I'm going to have to remove breast tissue out here laterally because I want a two-centimetre-thick  lateral pillar, but this is where the extra tissue is now, out and underneath that lateral flap. And so I'm going to put a coker on here.  Then when I come down, I'm going to leave a two-centimetre-thick lateral pillar and excise that extra lateral breast tissue.  You still need to do this even in older people, but in older people it's a bit easier to tailor  out with the liposuction, but with somebody like this who's 20 years old, you really need to carefully carve out all of that extra thick, solid breast tissue.  So after removing that inferior wedge of breast tissue, I've now gone underneath that lateral flap and removed this extra breast tissue.  You can still see, though, that there's still lateral breast tissue, thick, white, solid breast tissue, and I need to keep picking at that until I leave a good, wise pattern  of parenchyma down. If you leave extra breast tissue out here, you're going to get too much fullness laterally, so this needs to be carefully carved out.  So I've removed that inferior wedge of breast tissue, removed the lateral breast tissue underneath the lateral flap, true supramedial pedicle.  When the inferior border of the medial pedicle becomes the medial pillar, the pillars start here where your inverted T would start, not at the bottom of the skin opening and not  at the inframammary fold. So this can give you a good idea of what you're going to end up with, with a wise pattern  of parenchyma left behind and breast tissue excised, coddled to the wise pattern. And I will do a little bit of liposuction for tailoring just to give a good shape.  So my first suture is in the areola opening, and I find that this is the, this suture then I can get a better sense of what I have left there.  So into the areola opening, I didn't, you don't need to back cut or do anything to the dermis there, just get some dermis, and when I close this, there's no tension on this.  This is not a skin brassiere operation, and it's sometimes hard for people to switch from using a skin brassiere inverted T inferior pedicle to allowing loose skin, which heals  better without problems, and removing the inferior heavy breast tissue and leaving the superior breast tissue behind.  So once that first areola opening suture is put in, it's not difficult usually to pull the areola into position.  If it is blocked at all, then it's better to actually debulk deep, because remember the blood supply is in, just underneath the dermis for the veins, and that first centimeter  deep for the arteries, and if there's any tissue blocking areola or inset, then debulk it deeply, that's not where the blood supply is.  Now to pull the pillars together, the best maneuver is to pull up on your pedicle, you can see where the bottom of the pillars are, there's now the inferior border of my medial  pedicle has become my medial pillar. So my first suture is about halfway up that areola opening, and then here is my lateral pillar.  You don't need deep stitches, this isn't about grabbing great big bites of breast tissue, it's just about having it come together long enough so that medial and lateral pillars  touch each other and end up healing together. So it's again, no tension, it's not about tension.  I'll put three, maybe four sutures in the pillars, start at the bottom because I find  that easiest, then again, pull up on the pedicle, then you can find where your next suture should be where the two pillars meet together, and again, don't need deep sutures.  I use 3O Monocle Plus. The reason I use the plus, it has triclosan in it, it doesn't matter deep, but close to  the skin I think the triclosan, which is an antibacterial and not an antibiotic, can help reduce some of wound healing problems. So I've got two sutures.  Now I'm going to just again make sure that I get pillar to pillar apposition. Take a little bit in there, take that, and that's basically all I need.  Next I will do deep dermal sutures, then I'll do a little bit of liposuction for tailoring. I've done the excision of the inferior wedge and the lateral breast tissue.  I'm going to do a bit of liposuction for tailoring below where that Y's pattern would be.  This here is too thick, I need to get rid of that, that's not part of the breast tissue. We want the inframammary fold to keep curving up.  So I'm going to do a bit of liposuction here, here, you can do a little in the pre-axillary area as well.  So I've removed some of the extra fat under here with liposuction and removed some of this.  Now sometimes I would go out and take a little bit more out in the lateral chest wall, especially if she's chubby.  Some patients don't like that extra, she doesn't really have any extra pre-axillary fullness. But the way to get it is to go underneath the breast tissue up into that pre-axillary  area. Patients always want to get rid of it, but they actually need it, it's normal anatomy. But don't overdo this or else you'll get indentations.  And then you can extend a little bit more into the lateral chest wall to get rid of some of that.  So supramedial vertical breast reduction, I've taken a little more on the right side than I have the left. This is about 4 grams, this is about 425 or 450.  I think I'm actually going to probably just take a little bit more out of that. But if you notice, no gathering of that vertical incision.  What will happen is if you lift the breast up like this, you can see that that tucks in quite nicely.  And if that tucks in with this maneuver, not that maneuver, but lifting it up from the chest wall and tucking it in, then you don't need to add a T.  So we've left a Y's pattern of breast tissue behind, remove breast tissue, coddle to the Y's pattern, tailored that out with liposuction and used a true supramedial pedicle because  it has a dual axial blood supply. What we'll do now is add, at the end of the procedure we'll add paper tape. I don't believe in taping the breast itself, I don't think we need to.  Paper tape for the incision that will stay on for 3 or 4 weeks. I would use drains if I felt that it was too wet and there was too much oozing at the time.  But generally speaking, I don't think drains are necessary. She might get a bit of a seroma out here because of that lateral dissection, but seromas, because  there's no horizontal scar, the seroma will disappear quite easily over time. Patients get one dose of antibiotics, 2 grams of ANSEF at the beginning of the procedure,  no antibiotics afterwards. I think the 3O monocloplus with the triclosan in it and, more particularly, no tension on  the skin closure, then is what allows good healing without suture spitting and low-grade infection happening.  We allow her to have a shower the next day and activities are only restricted by comfort. We put her in a surgical brassiere, but more to just hold the bandages in place than to  actually give any kind of compression. We don't want too much compression on the areola anyway, so the bra is more just for comfort.

Video Summary

The procedure described is a supramedial vertical breast reduction performed to remove excess breast tissue while focusing on maintaining blood supply and sensation. The surgeon removes approximately 400 grams of tissue from the left breast and plans to replicate the process on the right breast. Emphasizing the importance of removing the internal breast tissue (parenchyma) rather than focusing solely on skin excision, the procedure employs a true supramedial pedicle for a dual blood supply to ensure safety and preserve sensation, particularly for maintaining nipple feeling. Adjustments include careful marking of incisions, removing excess tissue inferiorly and laterally, and using liposuction for tailoring. The surgeon stresses not relying on skin tension to maintain shape, opting instead for a method that allows the skin to naturally drape over newly shaped tissue. Post-procedure steps include using minimal sutures with an antibacterial component and suggesting light compression for comfort rather than tight garments.

Asset Caption

In this video, Elizabeth Hall-Findlay, MD, demonstrates a superomedial vertical breast reduction procedure on the right 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, performs the "pinch test" and outlines the excess tissue that will be removed. She discusses her infiltration strategy, outlines the blood supply topography of the breast and then performs the initial incisions and de-epithelization and discusses the different pedicle options and innervation before removing the inferior wedge of breast tissue. She then completes the operation and uses liposuction to refine the result. Surgeon Elizabeth Hall-Findlay, MD This product is not certified for CME.

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surgery spotlight

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Breast

Elizabeth Hall-Findlay MD; Memben

supramedial vertical breast reduction

breast tissue removal

blood supply preservation

nipple sensation maintenance

minimal sutures