Lowering Revision Rates in Medial Pedicle Breast Reduction by the Selective Use of a “Hybrid” Technique

Goals/Purpose:   The medial pedicle vertical-scar breast reduction is a popular technique with a high rate of patient satisfaction.  It has several distinct advantages over prior techniques, such as shorter scars, reduced operative times, and improved projection.  However, revision rates as high as 11% have been reported.  This study compares the results of two consecutive series of patients who underwent breast reduction by a single surgeon.  The first group consists of 51 patients who were treated between 2002 and August, 2007, with the medial pedicle vertical-scar technique.  Beginning in September, 2007, a “hybrid” technique was used in a select subset of patients, combining a medial dermoglandular pedicle with a modified Wise-pattern skin resection.  In the second group, consisting of patients treated between September, 2007 and 2011, 41 medial pedicle vertical reductions were performed and 35 “hybrid” breast reductions.  The purpose of the study is to compare the results between the two groups in order to determine if the revision rate following medial pedicle breast reduction can be lowered by the rational use of a modified Wise pattern in a subset of patients with macromastia.

Methods/Technique:   A review was made of 144 consecutive women who underwent breast reduction between 2002 and 2011.  The median age was 36 years, with a range from 16 to 69 years.  The mean follow up, defined as the time from surgery to most recent clinic visit, was 14 months (range 7-72 months).  11 patients underwent unilateral breast reduction as an adjunct to breast reconstruction, and they were excluded.  Six patients had a nipple transposition distance of greater than 20 cm and were treated with a free nipple graft technique, and these were also excluded from the analysis.  The remaining patients were divided into two groups.  Group 1 consisted of 51 patients, all of whom underwent a medial pedicle, vertical-scar breast reduction.  Four of these patients (8%) required a subsequent revision, consisting of excision of a dog-ear at the inferior aspect of the scar.  A logistic regression analysis was performed to determine which patient factors or measurements were predictive of the need for a revision.  Age, BMI, preoperative bra cup size, predicted weight of resection, degree of ptosis, and nipple-to-notch distance were not found to be significant predictors for revision.  However, an increased distance from the proposed nipple position to the inframammary fold (PNP-IMF) was found to be an independent risk factor for revision, (p=0.04).  All patients who required revision had a PNP-IMF distance greater than 22 cm.  Based on this, strict indications were adopted, where medial pedicle, vertical reductions were performed in all patients with a PNP-IMF distance less than 22 cm, with the remaining patients undergoing a “hybrid” breast reduction, combining a medial dermoglandular pedicle with a modified Wise-pattern skin resection, and employing a vertical limb length of 10 cm, pillar suturing, and a cinching closure of the vertical incision.  Group 2 consisted of 76 patients.  41 patients underwent a medial pedicle, vertical reduction, and 35 patients underwent the “hybrid” reduction.  The PNP-IMF distance was used to determine procedure type.  The two treatment groups were compared for homogeneity, using Student's t-test for parametric and Fisher's exact test for non-parametric data.  Revision rates, and the rates of minor and major complications were compared between the groups using Fisher's exact test.  Time of surgery was compared using Student's t-test.  Significance was defined as p<0.05.

Results/Complications:    Age, BMI, preoperative medical conditions, preoperative bra cup size, proposed size of reduction, and presence of a concomitant procedure were not found to differ significantly between the two groups.  The average size of reduction was 644±375g per side in Group 1, compared to 605±336g per side in Group 2, (p=0.54).  Breast liposuction was performed in 81% of patients in Group 1 and 74% in Group 2, (p=0.10).  Eight patients in Group 1 had concomitant procedures, as did 10 patients in Group 2.  The most common procedures were SAL of the hips and/or thighs (n=11), and abdominoplasty (n=10).  There were no major complications in either group.  Nine patients in Group 1 (18%) experienced one or more minor complications, as did 12 patients in Group 2 (16%), (p=0.62).  The most common complications were cellulitis (n=14), and delayed healing (n=9).  There were 4 revisions in Group 1 (8%), and 0 in Group 2 (p<0.001).  Mean operative time was 177 minutes (range 109-299) in Group 1, compared to 136 minutes (range 63-274) in Group 2, (p<0.001).

Conclusion:  Breast reduction employing a medially-based pedicle can be used effectively in a wide range of patients.  Using the PNP-IMF distance as the key criterion, a subset of patients can be identified who are at “high risk” for a secondary revision procedure.  Revision rates can be reduced by employing a modified Wise-pattern skin resection in these patients, while not significantly increasing complication rates or operative times.