Reduction Mammaplasty in Patients with a Medialized Nipple-Areola Complex (2013)

Sir:FigureWhen using traditional skin and dermoglandular markings for a breast reduction, a medialized nipple-areola complex can contribute to excessively short vertical limbs and tension on the closure/pedicle. This increased tension can predispose to abnormal nipple transposition with poor projection, wound dehiscence, or nipple-areola complex necrosis and/or diminished sensation.1,2 We propose a novel approach to preoperative marking of the keyhole skin pattern and superomedial breast reduction pedicle to compensate for a medially based nipple-areola complex. After institutional review board approval, a retrospective review was performed on all consecutive patients who presented for reduction mammaplasty from January of 2003 through January of 2009. The meridians of the breasts are marked based on the point of greatest projection or ptosis of the breast. The anticipated position of the nipple is then marked 2 cm above the inframammary fold along the breast meridian. Patients are recognized to have a “medialized” nipple-areola complex if the transposed nipple-areola skin is completely off the breast meridian. If so, the medial vertical limb of the Wise reduction skin pattern is increased in centimeters using a 1:1 ratio based on the lateral margin of the nipple-areola complex and the breast meridian, up to a total vertical limb of 10 cm. Beyond this length, medial pole distortion is increased, and the patient may be better suited for an inferior dermoglandular breast reduction. At the time of closure, the pedicle is also given a small backcut along the horizontal limb. This allows the dermoglandular pedicle to rotate into position superiorly, and augments the T-junction closure by bolstering vascularized tissue. A total of 32 patients were noted to have a medialized nipple-areola complex and underwent this technique. Two (6 percent) minor complications were recorded at follow-up, including one seroma that resolved following aspiration in the office, and one superficial skin cellulitis that responded to oral antibiotics. Twenty-five patients (78 percent) rated their results as excellent, and seven patients (22 percent) rated their results as fair. No partial or complete nipple-areola loss was noted in any patient. No patients described their outcome/satisfaction as poor. This is the first report to address the anatomical issue of a medialized nipple-areola complex while using the Wise pattern skin incision and superomedial dermoglandular pedicle for reduction mammaplasty. We have used this technique on 32 consecutive patients and consider it a superior method of managing a medially based nipple-areola complex, by decreasing the tension introduced on the pedicle and final closure, and improving the pedicle arc of rotation. The most common complications following classic skin patterns are based on either increased tension or decreased vascularity at the T-junction closure, as demonstrated by incisional dehiscence, partial skin loss, and inframammary scarring.3,4 Also, in the setting of small reductions or a medialized nipple-areola complex, the pedicle may be difficult to rotate for proper inset. The short medial vertical limb unfortunately prevents this rotation and instead displaces tension across the pedicle base and the T-junction skin closure.2 By instead planning ahead for this problem by lengthening the medial limb of the reduction pattern, this problem can be easily obviated. This modification to the superomedial reduction mammaplasty allows for a tension-free transposition of the nipple-areola complex to an ideal position on the breast mound for aesthetically pleasing results. By increasing the length of the medial vertical limb of the pattern, a reduction on the tension of the nipple/pedicle and final suture line is created without added glandular resection (Fig. 1 and Table 1).Fig. 1: (Left) Preoperative views demonstrating marked breast ptosis with a medialized nipple-areola complex. (Right) Postoperative views with excellent breast mound projection and a centralization of the nipple-areola complex along the breast central meridian.Table 1: Patient Demographics and Operative MeasurementsMatthew L. Iorio, M.D. Matthew Endara, M.D. Ivica Ducic, M.D., Ph.D. Department of Plastic Surgery, Georgetown University Hospital, Washington, D.C. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.