Treatment of Gigantomastia Using a Medial-Lateral Bipedicle Reduction Mammoplasty: The Role of Doppler-Assisted Preoperative Perforator Identification

Pedicle Selection and Design in Reduction Mammaplasty: The Role of Preoperative Fluorescence Imaging

BACKGROUND

Breast reduction has a wide selection of pedicles but often relies on the surgeon's preference and experience. Necrosis of the nipple-areola complex (NAC) is a catastrophic complication of breast reduction surgery.

OBJECTIVES

To solve the above problem objectively, we applied fluorescence imaging technology to the pedicle selection and design of breast reduction surgery for the first time, so that the dominant vessels of the NAC were included in the designed pedicle.

METHODS

We retrospectively enrolled 120 patients with breast reduction (a total of 239 breasts). We compared 60 patients who underwent breast reduction without fluorescence imaging for pedicle selection (Group A) with 60 patients who underwent pedicle selection with fluorescence imaging (Group B). The NAC blood supply was monitored after the operation.

RESULTS

In this study, 60 Group A cases (119 breasts) and 60 Group B cases (120 breasts) were analyzed. There were no statistically significant differences in patient demographic data or intraoperative resection weights. There were 7 cases of NAC necrosis in Group A (1 case of complete necrosis and 6 cases of partial necrosis), while no NAC necrosis occurred in Group B. There was a significant difference in the rate of NAC necrosis between the 2 groups.

CONCLUSIONS

Preoperative fluorescence imaging can guide the selection and design of breast reduction, significantly reducing postoperative NAC blood supply obstacles and necrosis.

LEVEL OF EVIDENCE: 3

Superomedial Pedicle Technique and Management of Circulation Problems in Gigantomastia : Treatment of Gigantomastia

Breast reduction surgeries encompass a wide range of methods that are continuously evolving to discover more reliable and satisfactory techniques. This presentation aims to address the research gap by sharing outcomes and experiences using the superomedial pedicle in gigantomastia, as well as the implemented protocol for managing nipple-areola complex (NAC) ischemia. The Wise pattern and superomedial pedicle reduction mammaplasty method were utilized in treating 19 patients (38 breasts). The average age of the patients was 41.47 years, with a basal mass index (BMI) of 33.27 kg/m2. The mean sternal notch to nipple (SN-N) length for the entire population was found to be 40.97 cm. On both sides, this length was statistically similar at 41.11 cm on the right side and 40.84 cm on the left side. The average weight of resected tissue from all patients was calculated to be 1793.42 g, with slightly higher weight on the right side at 1800 g compared to the left side's weight of 1786.84 g. Postoperative NAC ischemia occurred in three patients, one bilateral case, and two unilateral cases. The study revealed that in both the groups with and without NAC ischemia, the average values were as follows: age, which ranged from 45.33 to 40.75 years; BMI, ranging from 35.01 kg/m2 to 32.95 kg/m2; SN-N distance, which varied from 40 cm to 41.09 cm; and excision material weights, ranging from 1650 g to 1810.29 g. The p-value in the comparisons was found to be greater than 0.05. These results indicate that age, BMI, SN-N distance, and excision material weight did not have an impact on NAC vascularity issues. All NACs were successfully saved through a protocol involving hyperbaric oxygen therapy (HOT) and vacuum-assisted therapy (VAT). The study suggests that utilizing a superomedial flap is a viable option for treating gigantomastia and highlights the effectiveness of their outlined protocol in managing postoperative complications. While acknowledging the need for comparative studies, the study proposes incorporating HOT and VAT into protocols aimed at saving NACs.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-Sparing Gigantomastia Breast Reduction: A Systematic Review

INTRODUCTION

There remains an unclear definition of the term "gigantomastia," with many studies using different parameters and measurements. Currently, the operative management and patient education for gigantomastia are outdated. The historical teaching that a free nipple graft is necessary in elongated pedicles to avoid nipple necrosis may not be factual. The principal goal of our review aims to determine the safety of nipple-sparing breast reductions on large ptotic breasts via complication rate analysis.

METHODS

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of conduct for systematic review and meta-analysis. In October 2021, PubMed was used to search the US National Library of Medicine database. Rayyan Intelligent Systematic Review aided in screening studies by title then abstract. If inclusion criteria were met, the entire article was reviewed.

RESULTS

Twenty-two articles satisfied the inclusion and exclusion criteria. The study was composed of 1689 total patients with a mean body mass index of 32.9 (±3.4). Mean midclavicle-to-nipple distance and resection weight per breast was 39 cm (±3.8) and 1423.8 g (±268.9), respectively. A Wise pattern was preferred in 77.3% of the studies, with an inferior (45.5%) and superomedial (45.5%) pedicle used most commonly. Complete nipple areolar complex necrosis (1.7%) was found in 4 studies, whereas partial (5.9%) was observed in 11. More common complications included delayed wound healing (17.4%), surgical site infection (14.3%), seroma (10.5%), scar hypertrophy (9.9%), and wound dehiscence (9.2%).

CONCLUSION

Nipple-sparing breast reduction surgery can be safely performed on hypertrophic and severely ptotic breasts with nipple areolar complications, such as partial or complete nipple areolar complex loss, at a rate less than previously believed.

Multislice CT angiography as a roadmap for pedicle selection prior to breast reduction surgery

Background

Accurate knowledge of breast arterial supply on individual basis is crucial prior to breast reduction surgery to minimize the risk of post-operative necrosis of nipple-areola complex which is a well reported complication. The purpose of this cross-sectional study was to test the ability of multislice CT angiography to delineate the dominant arterial supply of nipple-areola complex to facilitate accurate breast pedicle selection to improve patient outcome.

Results

Twelve patients underwent multislice CTA of both breasts to delineate dominant arterial supply to NAC, internal mammary artery was the dominant arterial supply in most of breasts (87.5%) based on CTA findings and hence superomedial pedicle was the commonest pedicel chosen. None of patients experienced NAC necrosis postoperatively while minority of patients (16.6%) exhibited decreased NAC sensation bilaterally.

Conclusions

Multislice CT angiography is a useful pre-operative tool to minimize the risk of post-operative necrosis of nipple-areola complex in patients undergoing breast reduction surgery.

Double-Unit Superomedio-Central (DUS) Pedicle Inverted-T Reduction Mammaplasty in Gigantomastia: A 7-year Single-Center Retrospective Study

Introduction

Reduction mammaplasty in patients with gigantomastia is challenging. The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is the standard technique for reduction mammaplasty in our clinic. The aim of this study was to review our approach in cases with gigantomastia in comparison with the current literature.

Patients and Methods

From 01/2011 to 12/2017, we performed 831 reduction mammaplasties in 630 patients. The Double-Unit  Superomedio-Central  (DUS) pedicle and inverted-T incision was implemented as a standard procedure for gigantomastia. Patient demographics and the outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility, and surgical revision rate were obtained and retrospectively analyzed.

Results

In 37 patients, 55 reduction mammaplasties were performed with more than 1000 g per breast. Mean resection weight was 1311 g on right side and 1289 g on left side. Mean age was 52.5 years, mean body mass index was 32.8 kg/m², mean sternal-notch-to-nipple distance was 38.3 cm. A free NAC graft was necessary in four breasts. Overall complication rate was 14.5%; secondary surgical revision rate was 12.7%. 91% of the patients were “very satisfied” and “satisfied” with the aesthetic result. Nipple sensibility was rated “high” and “medium” in 83%.

Conclusion

The Double-Unit technique with a Superomedio-Central pedicle and inverted-T incision is very effective to achieve volume reduction and aesthetically pleasing reproducible results with a low complication rate in cases with gigantomastia.

Level of Evidence

Level of Evidence This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02351-y.

Nipple-Areola Complex Ischemia or Necrosis in Freestyle Perforator Flap Reduction Mammoplasty Operations

BACKGROUND

Necrosis of the nipple-areolar complex (NAC) is one of the most devastating complications of reduction mammoplasty. A variable, asymmetrical pattern of blood supply from the main sources was found in the same individual. To solve this problem, we present a method to be sure that the blood supply to the NAC is contained within the designed pedicle during reduction mammoplasty. This is done using the colored duplex scan and handheld Doppler to perform freestyle perforator flap reduction mammoplasty.

METHODS

This is a prospective randomized study that has been performed on 105 patients in the period between January 2014 and 2019 at the Plastic and Reconstructive Surgery Department, Tanta University Hospitals. Freestyle perforator flaps were performed for all cases after perforator detection using handheld Doppler and confirmed by colored duplex scan.

RESULTS

The procedure was performed as freestyle on medial perforators in 35 (33.3%) cases, on lateral perforators in 20 (19%) cases, on combined medial and lateral perforators, as a bipedicle in 30 (28.7%) cases, on upper pole perforators in 12 (11.4%) cases, and on lower pole perforators in 8 (7.6%) cases.

CONCLUSIONS

The use of handheld Doppler and the confirmation by duplex scan are mandatory to decrease the incidence of NAC necrosis or ischemia.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.