Monday, October 4, 2010
17194

The Superior Pedicle-Nipple Graft Technique Trumps Medial Pedicle Breast Reduction with Nipple Preservation for Management of Gigantomastia

Michele A. Shermak, MD, FACS, JHBMC Division of Plastic Surgery, 5th Floor Bldg A, 4940 Eastern Avenue, Baltimore, MD 21224, David Chang, PhD, MPH, MBA, General Surgery, UC San Diego, 200 West Arbor Drive, San Diego, CA 92103, Jessie Mallalieu, PA-C, Plastic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A 520, Baltimore, MD 21224, Kate Buretta, BS, Johns Hopkins School of Medicine, 4940 Eastern Avenue, Baltimore, MD 21224, Suhail Mithani, MD, Plastic Surgery, Johns Hopkins School of Medicine, Johns Hopkins Outpatient Center, 601 N. Caroline Street, Baltimore, MD 21287, and Michele Manahan, MD, Plastic Surgery, Johns Hopkins Hospital, Johns Hopkins Outpatient Center, 601 N. Caroline Street, Baltimore, MD 21287.

Purpose: While superior pedicle breast reduction with nipple grafting securely treats gigantomastia, several surgeons promote medial pedicle reduction with nipple preservation as the best technique for gigantomastia.1-5 We studied a large population treated by multiple plastic surgeons to study reliability of these techniques relative to each other and to the inferior pedicle technique. Methods: Medical records and operative reports of all reduction mammaplasty procedures performed over a 10 year period at an academic institution were retrospectively studied under an IRB protocol. Data recorded included: age, medical comorbidities, BMI, reduction technique, weights of resected tissue, and complications. Multiple logistic regression analysis was performed in Intercooled Stata 10. Significance was defined as p value < 0.05. Results: 1,192 consecutive patients underwent 2156 reduction mammaplasties performed by 17 plastic surgeons at our institution over a 10 year period. We studied patients who had > 1 kg resection per breast (n=709). Of these, techniques included inferior pedicle/Wise pattern (n=298, 42%); superior pedicle/nipple graft (n= 236, 33.3%); and medial pedicle/nipple preservation techniques (n=159, 22.4%). Overall complications for >1 kg reductions included: wound (n= 126, 17.8 %); scar (n= 93, 13.1%); fat necrosis (n= 76, 11%); infection (n= 66, 9.3%); and seroma (n= 23, 3.2%). We also evaluated reoperation for scar (n=51, 7.2%); fat necrosis (n=12, 1.7%); and wound (n= 9, 1.3%). On multiple logistic regression analysis, relative to inferior pedicle reduction, superior pedicle and medial pedicle techniques resulted in nearly equivalent, improved outcomes for infection (p=0.017/OR = 0.41 and p= 0.027/OR = 0.39, respectively) and reoperation for scar (p=0.05/OR = 0.40 and p= 0.03/OR = 0.28, respectively). Superior pedicle demonstrated a statistically significant advantage over medial pedicle technique for nonoperative wounds (p=0.002/OR = 0.41 vs. p=0.154/OR = 0.65) and wounds requiring reoperation (p=0.05/OR = 0.16 vs. p=0.45/OR = 0.51). Other variables increased complication risk, including secondary reduction (seroma, p=0/OR= 139, and reop for fat necrosis, p= 0.005/OR = 18.9); BMI (nonop wounds, p=0.06/OR =1.6); age (fat necrosis, p= 0.06/OR = 0.38 for age < 50 yrs); and cardiac disease (scar, p=0.05/OR = 3.8, and reop for fat necrosis, p= 0.057/OR = 7.34). Conclusion: While medial pedicle improves gigantomastia treatment relative to the inferior pedicle technique, in a large scale, side-by-side comparison, superior pedicle with nipple grafting assures the best outcome.

References 1. Casas LA, Byun MY, Depoli PA. Maximizing breast projection after free-nipple-graft reduction mammaplasty. Plast Reconstr Surg. 107:955, 2001. 2. Costa MP, Ching AW, Ferreira MC. Thin superior medial pedicle reduction mammaplasty for severe mammary hypertrophy. Aesthetic Plast Surg. 32:645, 2008. 3. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 115:1597, 2005. 4. Davison SP, Mesbahi AN, Ducic I, et al. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg 120: 1466, 2007. 5. Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle breast reduction for severe mammary hypertrophy. Plast Reconstr Surg. 105: 896, 2000.

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