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Bilateral Wise Pattern Inferior Pedicle Reduction Mammoplasty

We present a 16-year-old female with hypertrophic breasts of bra size 38H, bra strap grooving, and worsening back and posterior shoulder pain limiting activity and affecting posture, who underwent bilateral reduction mammoplasty using the Wise pattern inferior pedicle technique. 998 g of tissue was removed from the patient’s right breast, and 852 g of tissue was removed from the patient’s left breast. The procedure was uncomplicated; however, the postoperative period was complicated by minor skin breakdown at the most inferior portion of the incision along the inframammary fold, as well as some serous drainage that shortly resolved with treatment. Overall, the patient is satisfied with the results of the reduction. She reports comfortably wearing size 38C bras and has noticed significant improvement in back pain, shoulder pain, and bra strap grooving six months after the procedure.

Procedure: Bilateral Wise Pattern Inferior Pedicle Reduction Mammoplasty Introduction: The Wise pattern inferior pedicle resection remains the predominant technique for a reduction mammoplasty. Adaptations to accommodate preoperative breast size, desired breast size, and the expected degree of nipple transposition, are made based on the surgeon’s operative experience in achieving the desired results for each patient. Indications/Contraindications: The procedure is indicated in patients experiencing debilitating symptoms from breast hypertrophy. There are no absolute contraindications to this procedure. Materials and Methods: Preoperative markings are drawn to indicate the skin resection pattern, pedicle, and postoperative nipple placement. The pedicle is de-epithelialized and excess tissue is resected, as outlined by the markings. The skin is tailor-tacked to assess breast shape, symmetry, and new position of the nipple-areola complex. The incisions are closed with suture and secured with dressing. Results: A 16-year-old female with hypertrophic breasts of bra size 38H, bra strap grooving, and worsening back and posterior shoulder pain limiting activity and affecting posture, underwent a Wise pattern inferior pedicle reduction mammoplasty. The patient, now with bra size 38C, is satisfied with the results of the reduction and reports significant improvement in pain and bra strap grooving six months after the procedure. Conclusion: Reduction mammoplasties alleviate symptoms of breast hypertrophy, including neck and back pain, bra strap grooving, and limitations in activity. Future studies include pattern adaptations to encompass a wider range of breast sizes, research to support a consensus on drain placement, and research focused on reducing complications and improving postoperative outcomes.
Reduction mammoplasties aim to alleviate symptoms of hypertrophic breasts, such as chronic neck and back pain, bra strap grooving, and irritation in the inframammary fold, that are caused by the increased volume and weight of breast tissue beyond normal proportions. The diagnosis of breast hypertrophy is based on the relative volume of breast tissue when compared to overall body stature. Many women report impairment in daily activities, low self-esteem, and dissatisfaction with body image. Consequently, symptomatic breast hypertrophy is now recognized as a medical condition that requires management. Currently, an effective, long-term, nonsurgical treatment for breast hypertrophy does not exist. One study reports that less than one percent of women found permanent relief with nonsurgical treatments, including weight loss, support bras, and postural training. Therefore, surgical reduction is the best approach to long-term relief from symptomatic breast hypertrophy. In adolescents, breast hypertrophy can also have debilitating physical and psychological symptoms. Though these patients are good candidates for breast reduction, they must be counseled to prepare for a possible repeat surgery if their breasts increase in size as they grow older. A reduction mammoplasty with the inferior pedicle, inverted-T skin resection, and Wise pattern parenchymal resection, is the most widely used technique in the United States due to reproducible markings that often yield consistent results, and the adaptability of the pattern to accommodate most breast sizes. The surgeon must consider the challenges of anatomical variants and patient expectations to create the best outcome for each case. The procedure is indicated in any patient experiencing debilitating symptoms from breast hypertrophy; there are no unique contraindications to this procedure. Patients should meet the usual criteria for undergoing an operation under general anesthesia. A mammogram should be obtained on patients over forty years old or with a family history of breast cancer, and any suspicious findings should be discussed with an oncologist before the operation. As with most operations, early complications of a reduction mammoplasty are with proper wound healing, including hematomas, seromas, necrosis, and infection. These are prevented with careful hemostasis, drain placement, smoking cessation, and prophylactic antibiotic use. Common late complications are mainly cosmetic issues, such as asymmetry, improper breast shape, and unsightly scars. However, less common complications of loss of sensation to the breast or inability to breastfeed must also be discussed with the patient prior to the operation.
A reduction mammoplasty truly begins in the preoperative area with markings drawn with the patient in the standing position, or sitting upright, as shown in the video. Though the methods for a single breast are described, the procedure is performed bilaterally with identical methods and materials used on both breasts. All markings and guidelines are shown, labeled, and described in the video, unless otherwise stated. The suprasternal notch and midclavicular points are marked first, and a vertical line is drawn along the center of the chest to connect the suprasternal notch to the xiphoid process. Next, the breast meridian line is drawn from a marking approximately 6.5 cm lateral to the sternal notch. This line bisects the breast and may or may not coincide with the preoperative nipple position. Then, the inframammary fold is marked under the breast. Using a tape measure under the breast as a guide, or a hand as shown in the video, the proposed location of the new nipple-areola complex is marked at, or slightly below, the level of the inframammary fold, centered along the breast meridian line. The proposed location of the new nipple-areola complex should be approximately 21 cm from the suprasternal notch. After symmetrical height of the bilateral proposed nipple-areola complexes is ensured, the vertical limbs are drawn extending medially and laterally from the proposed nipple position. These lines should each be around 11 cm of length, and should be equidistant from the breast meridian. Next, a Lejour displacement is performed by gently pinching the breast to approximate the vertical limbs. The angle between the medial and lateral vertical limbs can be adjusted to determine the amount of tissue resected and how tight the skin closure will be. Then, the medial limit of resection is marked by displacing the gland laterally and connecting the inframammary fold line to the central vertical line. The lateral limit of resection is marked by displacing the gland medially and connecting the inframammary fold line to the central vertical line. Next, the location of the proposed nipple-areola complex is marked, creating a keyhole where the medial and lateral vertical limbs intersect the breast meridian line. Finally, the markings are all assessed bilaterally to ensure symmetry and to make any final adjustments. Once in the operating room, the patient is placed in a supine position with arms abducted and secured on the operating room table. The preoperative markings are then traced with a sterile marking pen, and symmetry is again confirmed bilaterally. The perimeter of a 44 mm diameter cookie cutter is traced and pressed firmly onto the skin, centered around the keyhole marking, to transfer the ink and create the outline of the new areola. Next, the inferior pedicle is designed, centered around the preoperative nipple-areola complex, with a base of 6-8 cm and a height extending 2 cm above the preoperative areola. A breast tourniquet is applied to secure and support the gland, as shown with Ray-tec® gauze in the video. Using a 10-blade, the epidermis is scored along the markings for the new nipple-areola complex and designed inferior pedicle. The inferior pedicle is then de-epithelialized, ensuring that no epidermis is left attached to the dermis. The breast tourniquet is then released to allow for mobilization of the tissue so the pedicle can be isolated. The incisions are continued deeper into the tissue with a cautery to dissect nearly to the chest wall. The inferior pedicle is isolated first as a column of tissue, widest at the base, preserving the areola. Then, all remaining breast tissue within the Wise pattern is resected to just above the pectoralis fascia. The medial and lateral flap excisions are carried out with the lateral being more liberal than the medial. The superior flap is thinned out to achieve coning and the desired shape of the breast. The resected tissue is then weighed to preserve consistency in the right and left breast. As depicted in the video, 998 g of tissue is removed from the patient's right breast, and 852 g of tissue is removed from the patient's left breast. The remaining pocket of tissue is irrigated copiously with bacitracin and light peroxide solution, and hemostasis is meticulously obtained. The skin is tailor-tacked with staples to form the inverted-T incision pattern by approximating the medial and lateral flaps to the inframammary fold. The areola is tailor-tacked to the keyhole area to approximate the new nipple-areola position. The patient is then raised to a seated position to evaluate for bilateral breast size and symmetry. If additional tissue needs to be removed, the deep side of the pedicle or the lateral flap can be thinned for further reduction. Once satisfied with the shape and amount of breast tissue remaining, a size 19-French drain is placed deep into the tissue pocket and sewn in with 2-0 silk suture. The incisions on the vertical limb and inframammary fold are closed with a 3-0 VICRYL® deep dermal suture and 3-0 STRATAFIX™ knotless MONOCRYL® running subcuticular suture. A 4-0 MONOCRYL® running subcuticular suture is used to secure the new areola to the keyhole area. The incisions are then secured with Mastisol® liquid adhesive and Steri-Strips™, and the patient is placed in a supportive bra with packing for added pressure and comfort. Drains are removed in a follow up clinic visit when fluid output is diminished, based on surgeon comfort and preference. All materials and methods described are shown in the video except for the supportive bra, which was placed on the patient in the postoperative period.
A 16-year-old female, presenting with hypertrophic breasts of bra size 38H, bra strap grooving, and worsening back and posterior shoulder pain limiting activity and affecting posture, underwent bilateral reduction mammoplasty using the Wise pattern inferior pedicle technique. 998 g of tissue was removed from the patient’s right breast, and 852 g of tissue was removed from the patient’s left breast. The procedure and immediate postoperative care were uncomplicated, with incisions well-approximated and without any evidence of infection. One month after surgery, she had minor skin breakdown at the most inferior portion of the incision along the inframammary fold, as well as some serous drainage. The breakdown remained superficial and was managed with Collagenase Santyl® and mupirocin ointment, along with Telfa™ dressing. The incision was completely healed within two weeks. Overall, the patient is satisfied with the results of the surgical reduction. She reports comfortably wearing size 38C bras and has noticed significant improvement in back pain, shoulder pain, and bra strap grooving six months after the procedure.
Symptomatic breast hypertrophy is recognized as a medical condition that requires management. Common symptoms include chronic neck and back pain, bra strap grooving, and a chronic rash in the inframammary folds. The increased weight and volume of the breasts can also lead to postural problems and may cause difficulty sleeping or breathing. Many women report impairment in daily activities, low self-esteem, and dissatisfaction with body image. Currently, an effective, long-term, nonsurgical treatment for breast hypertrophy does not exist. One study reports that less than one percent of women found full permanent relief with nonsurgical treatments, including weight loss, support bras, and postural training. Therefore, the best approach to permanent relief from symptomatic breast hypertrophy is with a surgical reduction. There are a variety of surgical techniques that the surgeon must decide between when approaching a surgical reduction, and they all involve the isolation of a pedicle, a skin resection pattern, and a parenchymal resection pattern. A reduction mammoplasty with the inferior pedicle, inverted-T skin resection, and Wise pattern parenchymal resection, is the most widely used in the United States due to reproducible markings that often yield consistent results, and the adaptability of the pattern to accommodate most breast sizes. The surgeon must consider the challenges of anatomical variants and patient expectations to create the best outcome for each case. For example, the Wise pattern inferior pedicle technique with an inverted-T skin resection is the ideal choice for a very large breasts with over 1500 g of breast tissue resected. However, if the breast is small and the resection is likely to be less than 500 g of tissue, a vertical skin resection technique with either a superior or medial pedicle may be preferred. The Wise pattern inferior pedicle technique is also favored because blood circulation to the pedicle from the fourth and fifth intercostal arteries is preserved, and there is a lower risk of loss of sensation of the nipple and loss of lactation function of breast tissue when compared to several other methods. The other resection patterns and pedicle placements are not discussed in detail due to the focus of the video on the Wise pattern inferior pedicle technique. When planning a reduction mammoplasty, the preoperative markings are crucial to the placement of the postoperative nipple, and to determine the amount of tissue that will be resected. The ideal nipple position is slightly below the middle of the breast mound. The level of the inframammary fold is often used as a guide to mark the new position of the postoperative nipple, as described in the methods section. It is recommended to place the mark slightly below the inframammary fold because it is easier to raise a nipple that has been positioned too low than to lower a nipple that has been positioned too high. The angle created by the vertical limbs correlates with the amount of tissue that will be resected and will depend on the size of the breast. Due to natural asymmetry and anatomical variants, the most important determinant of postoperative breast size is the amount of tissue remaining and not what is removed. Therefore, it is recommended that the surgeon pinch the vertical limbs together to estimate and visualize what the final incisions, nipple placement, and remaining tissue will be. Another crucial step is to ensure symmetry in the size of the breasts after the excess tissue has been resected. Evidence indicates that the volume of breast tissue resected is not correlated to the amount of postoperative symptom relief; therefore, the reduction is more accurately defined and guided by individual symptoms and preferences rather than by breast volume alone. The surgeon should discuss the desired postoperative breast size with the patient prior to designing the preoperative markings. The procedure is indicated in any patient experiencing debilitating symptoms from breast hypertrophy; there are no unique, absolute contraindications to this procedure. Patients should meet the usual criteria for undergoing an operation under general anesthesia. A mammogram should be obtained on patients over forty years old or with a family history of breast cancer, and any suspicious findings should be discussed with an oncologist before the reduction. As with most operations, wound healing problems dominate the early complications and can lead to skin breakdown at the incision sites, as demonstrated by our patient. These complications can include hematomas, seromas, necrosis, and infection. Incidence of these problems correlate with the amount of tissue resected. Hematomas are avoided with careful hemostasis prior to closing each breast. Seromas are less common, and most are spontaneously reabsorbed in the post-operative period. Seromas are less likely to be absorbed with the inverted-T skin resection pattern because scarring at the level of the inframammary fold can block the fluid from draining. Therefore, drain placement has been widely used with this technique, as shown in our video, to prevent the fluid from accumulating. Recent evidence suggests that the use of drains is neither beneficial nor harmful when considering postoperative complications. Some studies suggest that they serve as a source of discomfort for patients and could possibly lengthen their stay the hospital. There is currently no consensus on drain use, and surgeons mainly decide on drain placement based on their previous experiences. Tissue necrosis is a feared complication of a reduction mammoplasty, but it is uncommon unless the patient is a smoker. Smoking cessation is encouraged in all patients prior to undergoing an operation, and the association between smoking and tissue necrosis should be discussed with the patient during consent. Another early complication of the procedure is infection, yet it is uncommon unless there is vascular compromise, usually due to tight closure of the skin. Excess compression during the postoperative period is also not advised, to prevent compression of the circulation to the nipple-areola complex. Prophylactic antibiotics are used in many patients undergoing a surgical reduction in efforts to prevent this complication. Common late complications are mainly cosmetic issues, such as asymmetry, improper breast shape, and unsightly scars. Many of these complications can be addressed postoperatively with a second surgery that is focused on the aesthetics of the breast, or with non-surgical treatments, such as scar therapies. Liposuction is occasionally performed after a reduction to reshape the peripheral tissue and address any asymmetry. Less common complications of reduction mammoplasties include loss of sensation to the breast or inability to breastfeed. These issues, though uncommon, must be discussed with the patient prior to the operation, especially in the adolescent population or in women who plan to breastfeed in the future. As with all operations, the risks and possible complications should be discussed with the patient prior to obtaining consent. Reduction mammoplasties are effective treatments for alleviating the physical and psychological manifestations of symptomatic breast hypertrophy, including chronic neck and back pain, bra strap grooving, and limitations in daily activity, thereby improving the quality of life for these patients. The Wise pattern, inverted-T scar reduction with the inferior pedicle remains the predominant operative technique chosen by plastic surgeons in the United States. Adaptations to accommodate preoperative breast size, desired breast size, and the expected degree of nipple transposition, are made based on the surgeon’s operative experience in achieving the desired results for each patient while minimizing any postoperative complications. We present a 16-year-old female with hypertrophic breasts of bra size 38H, bra strap grooving, and worsening back and posterior shoulder pain limiting activity and affecting posture, who underwent bilateral reduction mammoplasty using the Wise pattern inferior pedicle technique. The procedure was uncomplicated; however, the postoperative period was complicated by minor skin breakdown at the most inferior portion of the incision along the inframammary fold, as well as some serous drainage that shortly resolved with treatment. Overall, the patient is satisfied with the results of the reduction. She reports comfortably wearing size 38C bras and has noticed significant improvement in back pain, shoulder pain, and bra strap grooving six months after the procedure. Future studies of the Wise pattern inferior pedicle reduction mammoplasty technique include adaptations to safely encompass a wider range of breast sizes and shapes, research to support a consensus on drain placement, and research focused on reducing wound healing complications and improving postoperative outcomes.
The contributors to this video have no conflicts of interest or financial conflicts to disclose.
The contributors would like to thank the Department of Plastic and Reconstructive Surgery at Arkansas Children’s Hospital and the University of Arkansas for Medical Sciences for making this study possible. We would also like to thank CSurgeries for the educational opportunity that it provides.
1. Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plastic and Reconstructive Surgery. 2012;130(4):785-789. doi:10.1097/prs.0b013e318262f0c0. 2. Wolfswinkel E, Lemaine V, Weathers W, Chike-Obi C, Xue A, Heller L. Hyperplastic Breast Anomalies in the Female Adolescent Breast. Seminars in Plastic Surgery. 2013;27(01):049-055. doi:10.1055/s-0033-1347167. 3. Purohit S. Reduction mammoplasty. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India. 2008;41(Suppl):S64-S79. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825129/ 4. Hall-Findlay EJ, Shestak KC. Breast Reduction. Plastic and Reconstructive Surgery. 2015;136(4). doi:10.1097/prs.0000000000001622. 5. Siy R, Khan K, Izaddoost S, Brown R. The Superomedial Pedicle Wise-Pattern Breast Reduction: Reproducible, Reliable, and Resilient. Seminars in Plastic Surgery. 2015;29(02):094-101. doi:10.1055/s-0035-1549052. 6. Greco R, Noone B. Evidence-Based Medicine. Plastic and Reconstructive Surgery. 2017;139(1). doi:10.1097/prs.0000000000002856. 7. Sachs D, Szymanski KD. Breast, Reduction. [Updated 2017 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.

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