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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
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15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.9 Glandular resection in the classical inferior pedicle
technique
Fig. 15.7 Vascular anatomy of the inferior pedicle
Fig. 15.8 Lateral and medial resection
Fig. 15.10 Glandular resections in the classical inferior pedicle
technique
Fig. 15.11 Markings are illustrated
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K. S. Bhangoo
Fig. 15.12 De-epithelialization of the inferior dermal pedicle
Fig. 15.13 Illustrates the inferior pedicle and the amount and extent of
glandular resection
Figure 15.13 illustrates the inferior pedicle and the
amount and extent of glandular resection.
Figures 15.14 and 15.15 show temporary approximation
of aps after glandular resection.
Figure 15.16 shows transposition of the nipple areola
complex.
Figures 15.17 and 15.18 show the results of the classical
inferior pedicle technique.
Fig. 15.14 Temporary approximation of aps after the glandular
resection
Fig. 15.15 Flaps approximated with towel clips
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.16 Transposition of the nipple areola complex
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Fig. 15.17 Lack of upper pole fullness with the classical inferior pedicle technique
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K. S. Bhangoo
Fig. 15.18 Lack of upper pole fullness with the classical inferior pedicle technique
15.6 Drawbacks ofInferior Pedicle
Technique
Although inferior pedicle technique is most commonly used,
it has several drawbacks. There is lack of fullness and attening of the upper pole with time (Fig.15.19). There is frequently retraction of the nipple areolar complex. This is due
to excision of breast tissue in the upper pole. Sometimes
there is compromise of circulation to the nipple areolar complex. Lactation is impaired. Sensation to the nipple areolar
complex is also frequently diminished or absent. There is a
signicant incidence of fat necrosis resulting in painful
lumps (Fig. 15.20a, b). The lateral aspect of the reduced
breast frequently has a square, boxy, and unesthetic look.
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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Fig. 15.19 Lack of upper pole fullness with the classical inferior pedicle technique
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a
b
Fig. 15.20 (a) Fat necrosis following breast reduction. (b) Fat necrosis excised
15 Breast Reduction Inferior Dermal Pedicle Technique: Modied
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15.7 Personal Modication ofInferior
Pedicle Technique
The author has modied the inferior pedicle technique to
overcome some of the drawbacks mentioned above. In this
technique, a bipedicle vertical dermal glandular pedicle is
used (Fig.15.21). Unlike the classical inferior pedicle technique, the breast tissue from the upper segment is not resected
at all (Fig.15.22). This preservation of the glandular tissue in
the upper segment results in preservation of fullness and lack
of attening of the upper pole (Fig.15.23). It also results in
maintaining nipple projection and prevents nipple retraction
by providing bulk and padding under the nipple areolar complex. There is better overall circulation resulting in reduced
incidence of fat necrosis. The square and boxy lateral appearance is corrected by doing liposuction at the end of the
procedure.
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Fig. 15.23 Vertical dermoglandular bipedicle after medial and lateral
glandular resection
Since adopting this technique, the author has noticed
absence of wound dehiscence problems and nipple areolar
circulatory impairment as well as elimination of fat necrosis.
Patients have also been able to breast feed following this
technique. There has been an improvement in the contour of
the breast with preservation of upper pole fullness and prevention of bottoming out.
The technique will be discussed under the following
headings:
Fig. 15.21 Vertical dermoglandular bipedicle
Fig. 15.22 Lateral and medial resection
1. Markings
2. De-epithelialization and pedicle formation
3. Lateral resection
4. Medial resection
5. Approximation of the skin aps
6. Transposition of the nipple areolar complex
7. Liposuction of the lateral breast
15.8 Markings
Before embarking on any breast surgery, the surgeon should
have a proper understanding of the measurements of the normal esthetic breast (Fig.15.24).
Accurate marking is extremely important in planning this
surgery. If the markings are done right, then everything falls
into place. It is important to understand the measurements of
an esthetically pleasing breast. These are shown in the gure.
The author does not use the Wise pattern which predetermines the position of nipple areola complex (Wise 1956).
Using the method described below allows the placement of
nipple areola complex at the desired level. This allows exibility which is not possible with the Wise pattern.
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Fig. 15.24 Breast esthetics
K. S. Bhangoo
The rst step in markings is to determine the new position
of the nipple areolar complex. This is done in several ways.
One is to place it opposite the inframammary fold. It can
also be determined as mid-point of the distance between the
acromion and the olecranon process of the arm. The third
way is to place it approximately 21cm from the midclavicular point, along the verticle meridian along the existing nipple areola complex (Fig. 15.25). This distance can vary
depending on the height of the patient. In my experience, the
most reliable method is to place it opposite the inframammary fold by placing a nger under the breast in the inframammary fold and then putting a mark at that level on the breast
anteriorly (Figs.15.26 and 15.27).
The next step is to mark the meridian from the midclavicular point to the nipple areolar complex down to the inframammary fold (Fig.15.28).
Next an arc measuring 12–14cm in length is marked on
either side of the nipple areolar complex, this being points B
and C (Fig.15.29). The distance between A and B and A and
C will become the verticle limb of the inverted T incision.
The upper 4cm will be for the nipple areola transposition,
leaving the lower 8–10cm as the distance between the nipple
areola complex and the inframammary fold. The distance
between point B and C will determine the extent of the
reduction (Fig. 15.30). This angle between B and C will
determine how much breast tissue is to be resected. If a small
reduction is planned, this angle is narrow. For larger reductions, this angle is wider. In most cases, the distance between
B and C is between 17 and 20cm.
Fig. 15.25 Pre-operative markings
Next, the inframammary incision is marked; this being D,
F, and E in the diagram. The point F is raised upward
(Fig. 15.31). This will prevent circulatory problems and
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Fig. 15.26 Marking new nipple position
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Fig. 15.27 Marking new nipple location with reference to inframammary crease
wound healing issues at the conuence of the aps by
decreasing tension. This elevation of the incision at point F
makes a big difference in ensuring a satisfactory healing at
this normally precarious point. The distance between D and
C is twice the distance between B to D and C to E.The distance B to D and C to E equals D to E.In this manner, there
will be no dog ear when all the aps are approximated
(Fig.15.32).
Next, the inferior pedicle is outlined. This is usually 8cm
in width, being 4cm on either side of point F and extending
to a distance approximately 4cm from point A on either side.
Fig. 15.28 New location of the nipple 21cm from midclavicular line
and suprasternal notch
This is a vertical bipedicle dermal glandular pedicle marking. Sometimes there is accessory axillary breast, and this
can be outlined, and it can be treated by liposuction at the
end of the procedure.
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K. S. Bhangoo
Fig. 15.29 Markings
Fig. 15.31 Upward curve in the mid-inframammary incision is
important
Fig. 15.30 This distance will determine the amount of resection
Fig. 15.32 This limb should be half the length of the inframammary incision to avoid a dog ear
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