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

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.