BREAST...hypertrophy, with breast weight greater than 1500 g, as opposed to a mean breast weight,inFrance,of300g.Itisoftenseeninobese patients. Gigantomastia can be idiopathic with

BREAST

Breast Reduction in Gigantomastia Using thePosterosuperior Pedicle: An AlternativeTechnique, Based on Preservation of theAnterior Intercostal Artery Perforators

Ali Mojallal, M.D.Michel Moutran, M.D.Christo Shipkov, M.D.Michel Saint-Cyr, M.D.

Rod J. Rohrich, M.D.Fabienne Braye, M.D.

Lyon, France; and Dallas, Texas

Background: The purpose of this study was to describe and evaluate the out-comes of breast reduction in cases of gigantomastia using a posterosuperiorpedicle.Methods: Four hundred thirty-one breast reductions were performed between2004 and 2007. Fifty patients of 431 (11.6 percent) responded to the inclusioncriteria (�1000 g of tissue removed per breast (100 breasts). The mean age was 33.2years (range, 17 to 58 years). The average notch-to-nipple distance was 37.9 cm(range, 35 to 46 cm). The mean body mass index was 27 (range, 22 to 35 cm). Thetechnique of the posterosuperior pedicle was used, in which the perforators fromfourth anterior intercostal arteries are preserved (posterior pedicle). Results wereevaluated by means of self-evaluation at 1 year postoperatively.Results: The average weight resected was 1231 g (range, 1000 to 2500 g). Thelength of hospital stay was 2.3 days (range 2 to 4 days). Thirty seven patientsevaluated their results as “very good” (74 percent), nine as “good” (18 percent), andfour as “acceptable” (8 percent). There were no “poor” results. The chief complaintwas insufficient breast reduction (four patients), despite the considerable improve-ment in their daily life (8 percent). Back pain totally resolved in 46 percent andpartially (with significant improvement) in 54 percent of cases. One major and sevenminor complications were recorded.Conclusions: The posterosuperior pedicle for breast reduction is a reproducibleand versatile technique. The preservation of the anterior intercostal artery perfo-rators enhances the reliability of the vascular supply to the superior pedicle. (Plast.Reconstr. Surg. 125: 32, 2010.)

Gigantomastia is defined as excessive breasthypertrophy, with breast weight greaterthan 1500 g, as opposed to a mean breastweight, in France, of 300 g. It is often seen in obesepatients. Gigantomastia can be idiopathic with

normal body mass index, idiopathic with highbody mass index, or associated with some hor-monal disturbances, as in puberty gigantomastiaand pregnancy gigantomastia.2 Rare cases of druginduced gigantomastia have been reported in-criminating penicillamine,3 neothetazone,4 andciclosporine.5 In cases of gigantomastia, severeptosis is usually present (a sternal notch-to-nippledistance superior to 32 cm as defined in ourpractice),6 with occasionally compromised vascu-lar supply to the nipple-areola complex. The rec-ommended surgical procedure for gigantomastia,until recently, was the Thorek procedure, in whichthe nipple-areola complex is harvested and trans-

From the Department of Plastic, Reconstructive and AestheticSurgery, Edouard Herriot Hospital, University of Lyon-France, and the Department of Plastic Surgery, University ofTexas Southwestern Medical Center.Received for publication February 27, 2009; accepted July28, 2009.Presented at the International Society of Aesthetic PlasticSurgery Meeting 2006, in Rio de Janeiro, Brazil; the Inter-national Plastic, Reconstructive and Aesthetic Surgery Meet-ing 2007, in Berlin, Germany; and the French Society ofPlastic Reconstructive and Aesthetic Surgery Meeting 2007,in Paris, France.Copyright ©2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181c49561

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com32

ferred to its new position.7–9 The main disadvan-tages of this technique are the risks of total orpartial necrosis of the nipple-areola complexgraft, loss of any future breast feeding, nipple-areola complex discoloration and loss of sensitiv-ity, and finally, possible loss of nipple-areola com-plex projection.2 Although successful refinementsof the technique were reported, no complete res-olution of all problems was achieved.10–13

The indications of free nipple-areola complexgraft significantly decreased with the spread of the“conservative” techniques, based on the nipple-areola complex transposition on a reliable vascu-larized pedicle, with improved results. However,few authors used the superior pedicle techniques forbreast reduction in cases of gigantomastia.14 Previ-ously published reports focus on the inferior pedicletechniques15 or the McKissock’s bipedicled nipple-areola complex transposition16 or the superomedialpedicle breast reduction.17 The goal of this studywas to describe the posterosuperior pedicle tech-nique of breast reduction in gigantomastia, basedon the perforators of the anterior intercostal ar-teries, and to present the prospective results of 50consecutive patients.

PATIENTS AND METHODSThis study was conducted after obtaining ap-

proval by the Institutional Review Board of theUniversity of Lyon. Four hundred thirty-onebreast reductions were performed at our institu-tion between January of 2004 and January of 2007.All overweight patients were advised to reduce andstabilize their body weight before surgery. Patientswere also advised to stop smoking at least 1 monthbefore surgery. Fifty of 431 patients (11.6 percent)responded to the inclusion criteria (�1000 g oftissue removed per breast; 100 breasts). The meanage was 33.2 years (range, 17 to 58 years). Theaverage notch-to-nipple distance was 37.9 cm(range, 35 to 46 cm). Twenty-eight patients (56percent) had a body mass index superior to 25.The mean body mass index was 27 (range, 22 to35). Thirteen patients (26 percent) previously hadundergone a bariatric procedure for weight re-duction and 12 (24 percent) had undergone anabdominoplasty. Eight patients presented with di-abetes mellitus, without the need for insulin admin-istration (16 percent), and five smoked regularly (10percent). Patient data are listed in Table 1.

None of the patients had any previous breastsurgery. All patients reported dorsal and cervicalpain. A written consent form was signed by all

patients. In cases with language barrier the visualdocumentation of oral consent, as described byDanino et al., was used.18

The lower age limit for reduction mamma-plasty was 17 years. Under this age, patients werereferred to pediatric endocrinologists for follow-up. Patients with juvenile and postgravid giganto-mastia were also referred to specialists in order torule out metabolic disorders.

The breast tissue removed was weighed anddocumented at the time of surgery. The breastswere not infiltrated before weighing.

The evaluation criteria were as follows: dura-tion of surgery, length of hospital stay, complica-tion rate, duration of dressing care, and patientsatisfaction. Medical records were reviewed atpostoperative days 15 and 30, and at 3 months, 6months, and 1 year.

Subjective and objective methods were used toevaluate the results. Patient satisfaction was eval-uated at 1 year and was rated as “very good,”“good,” “acceptable,” or “poor” by the patient.The same scale was used by an unbiased third-party jury.

The subjective method included a self-evalu-ation anonymous questionnaire, sent to all pa-tients, accompanied by an explanatory letter. Thequestionnaire with the corresponding responseswas then mailed back to the surgeon and then theinformation recorded and analyzed.

We have used the method of closed-endedquestion scale for collecting and evaluating theresults. The objective method was based on eval-uation of preoperative and postoperative pho-tographs by five adults (three women and twomen), not doctors, nurses, or other medical

Table 1. Patients’ Data before Surgery*

Characteristic Value (%)*

No. of patients 50Mean age (yr) 33.2Sternal notch-to-nipple distance (cm)

Mean 37.9Range 35–46

BMIMean 27Range 22–35

No. of patients with idiopathicgigantomastia with high BMI 28 (56)

No. of patients with idiopathicgigantomastia with normal BMI 15 (30)

No. of patients with juvenile gigantomastia 5 (10)No. of patients with post-gravid gigantomastia 2 (4)No. of patients with diabetes mellitus 8 (16)No. of smokers 5 (10)BMI, body mass index.*Percentage of all patients.

Volume 125, Number 1 • Breast Reduction in Gigantomastia

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staff. Photographs of each patient (frontal,oblique, and profile) were presented to the juryon a computer screen: on the left, a preoperativephotograph; and on the right, a postoperativephotograph. The photographs were of the samedimensions, brightness, and contrast. The pre-sentation was performed using Power Point, Mi-crosoft Office software (Microsoft Corp., Red-mond, Wash.). The duration of each casepresentation was 20 seconds. The raters wereasked to evaluate the result as “very good,”“good,” “acceptable,” or “poor.”

Surgical Key Points

Vascular Supply to the BreastIn gigantomastia, the vascular anatomy of the

breast remains the same but the breast is more ptoticwith an increased sternal notch-to-nipple distanceand broad base (Fig. 1). Various reports19–21 haveemphasized the fact that the vascular supply to thenipple-areola complex relied mainly on perforatingarterial branches from (1) the internal mammaryartery, (2) the lateral thoracic artery at the level ofthe fourth intercostal artery, and (3) the anteriorintercostal artery at the level of the mid fourth and

Fig. 1. Anterior intercostal perforators from the fourth and fifth intercostal spaces. Schematic pre-sentation after Würinger et al. (Nerve and vessel supplying ligamentous suspension of the mammarygland. Plast Reconstr Surg. 1998;101:1486 –1493). (Left) Illustration of gigantomastia with breast ptosisbelow the inframammary fold and hollowness of the superior quadrants. ( Right) The zone of resectioncaudal to the horizontal septum is shown in gray.

Fig. 2. Computed tomographic angiography scan of a cadavericspecimen and anterior intercostal perforators at the fourth andfifth intercostal space (blue arrows).

Plastic and Reconstructive Surgery • January 2010

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mid fifth intercostal space (Figs. 2 and 3). Thislatter artery is crucial in our technique, as we in-clude it in the pedicle. Würinger et al.22 describeda horizontal septum, which divides the breast intosuperior and inferior portions. This septum con-tains the vascular and nerve supply to the nipple-areola complex in a mesenteric-like manner. Thefibrous horizontal septum is a key point in ourtechnique because the perforators from the an-terior intercostal artery emerge from the pec-toralis major muscle at the level of the fourthand fifth intercostal space, and run in this hor-izontal septum.22 Our technique combines thesuperior dermal pedicle and the posterior vas-cular pedicle to the nipple-areola complex (cen-tral mound technique).

Posterosuperior Technique

Preoperative MarkingsThe preoperative markings are performed with

the patient in the standing position (Figs. 4 and 5).First, the midthoracic vertical axis is drawn fol-lowed by both inframammary folds. From a fixedpoint, 5 cm lateral to the sternal notch, a line tothe nipple, representing the axis of each breast, isdrawn. The axis is continued below the inframam-mary fold on the thoracoabdominal skin. This lineis usually at 10 to 12 cm from the midthoracic line.Then, point A (upper pole of the future areola) onthe breast axis (corresponding approximatelyto the level of the inframammary fold) is marked.The medial and lateral arms of the “keyhole” are

Fig. 3. Schematic presentation of the fourth and fifth intercostal arteries perforators and nerves forthe nipple-areola complex and the horizontal septum in cases of gigantomastia. The zone of resec-tion and the vascular supply from the anterior intercostal perforators are presented on the left smallillustration.


35

marked, moving the breast laterally and medially(maneuver described by Bisenberger,23 as twostraight vertical lines from point A down across theinframammary fold following the breast axis.Points B and B= are marked at 7 to 8 cm from point

A. BB= is the width of the nipple-areola complexbearing pedicle. A 1:2 width-to-length ratio of thepedicle is respected. This renders the dermal vas-cular supply to the nipple-areola complex morereliable. AB and AB� are the diameters of twosemicircles that will form the future areola. PointsC and C� are marked on the straight lines of thekeyhole 6 cm from B and B=. BC and BC� are thefuture distance from the nipple-areola complex tothe inframammary fold. This distance is limited to6 cm (overcorrection) to anticipate future second-ary breast ptosis. Drawings are completed by join-ing vertically points C and C= to the inframammaryfold (Fig. 4). The width of the horizontal inferiorincision should not exceed the mammary projec-tion area.

Operative ProcedureThe patient is operated on in a semisitting

position. The future areola complex is markedwith a “cookie cutter” (45 mm in diameter) Thenipple-areola complex bearing pedicle is deepi-thelialized. The incisions are made following thepreoperative drawings. Glandular resection isstarted in the lower central portion of the breast,beginning from the inframammary fold incision.The resection is stopped when the inferior borderof the pectoralis major muscle is reached. Resec-tion is then continued to the lateral extension andinferomedial portion of the breast. Two glandulartriangles are resected in the inferior lateral andmedial breast regions, to allow better shaping ofthe breast (Fig. 4). The dermoglandular superiorpedicle is then incised and suspended verticallywith hooks. The glandular resection joins the dis-tal part of the nipple-areola complex bearing pedi-cle and is limited to a plane joining caudally theinferior border of the nipple-areola complex bear-ing pedicle and the pectoralis major muscle, ce-phalically. The result is a pedicle thinner towardits tip and thicker toward its pectoralis major or-igin. Its anatomical design is justified by the im-portance of the vascular supply to the nipple-are-ola complex from the dermoglandular flap, whichis enhanced by the direct perforator of the ante-rior intercostal artery at the level of the fourth andfifth intercostal space. At this point, the range ofmotion of the nipple-areola complex pedicle islimited by the nipple-areola complex tractionfrom the fibrous horizontal septum, described byWüringer.22 The posterior sheath of the horizon-tal septum may be carefully incised to render thepedicle more pliable. Perforators from the ante-rior intercostal artery emerge from the pectoralismajor muscle, at the level of the fourth and fifth

Fig. 4. Schematic presentation of the preoperative drawings;the filled area represents the zone of undermining. IMF, infra-mammary fold.

Fig. 5. Preoperative markings of a patient in the upright posi-tion. A diameter of 7 to 8 cm of the areolar circle, drawn preop-eratively, allows a length-to-width ratio of approximately 2:1.


36

intercostal space, and are cranial to this posteriorsheath of the horizontal septum (Figs. 3 and 6).

The glandular resection involves the inferiorpole of the breast with its medial and lateral ex-tensions.

Pedicle plication can be facilitated by means ofdigital softening (digitoclasia) of the dermoglan-

dular pedicle without injuring the blood vessels. Insome cases, gentle lipoaspiration of the pediclewith a 3.6-mm cannula can reduce its density andfacilitate its plication.

To also preserve the blood supply to the breastparenchyma and nipple-areola complex from theperforating branches of the internal mammaryartery, a limited tunnel 4 to 5 cm wide is dissectedabove the pectoralis major fascia (Fig. 7). The roleof this tunnel is to reach the superior pole of thebreast and to facilitate the plication and suspen-sion of the reduced breast by gliding over thepectoralis fascia. We make the tunnel between theanterior intercostals artery perforators and inter-nal mammary artery perforators to preserve bothvascular supply to the breast.

The lateral pillar of the breast is anchored tothe fascia of the pectoralis major muscle in theretroglandular tunnel with three resorbable su-tures of 1.0 size. The role of these sutures is (1) tomodify the distribution of the mammary glandwithin the new reduced breast, (2) to control thelateral extension of the breast and define the lat-eral mammary fold, while reducing the base di-ameter of the breast, and (3) to decrease the ten-sion on the anchoring sutures. In cases of axillaryadipose extension, complementary lipoaspirationin the lateral thoracic area can be used. A singledrain is used for each breast and incisions are

Fig. 6. Intraoperative view after careful opening of the inferiorsheath of the horizontal septum. The fourth and fifth anteriorintercostal perforators, directed to the nipple-areola complex,can be visualized as a darker, vertical line in the center of thepedicle (arrow). This pedicle must be respected to enhance thevascular supply and preserve the sensibility of the nipple-areolacomplex.

Fig. 7. (Left) Intraoperative view of the right breast after resection. The vascular supply is preserved. Amedial subglandular tunnel was meticulously undermined between the internal mammary perforatorsand anterior intercostal perforators for anchoring the lateral breast pillar and lateral pexy. (Right) Finalclosure of the right breast.


37

closed with resorbable 3-0 and 4-0 monofilamentsutures (Fig. 7). Drains are usually removed 48hours following surgery.

RESULTSThe mean follow-up period was 16 months

(range, 13 to 23 months). The average weightresected was 1231 g (range, 1000 g to 2500 g). Theaverage duration of surgery was 2h (range, 1.50 to2.30 hours). The average length of hospital staywas 2.3 days (range, 2 to 4 days). The durationof the outpatient postoperative care until com-plete wound healing was 15.2 days (range, 13 to20 days). Results are listed in Table 2.

One major complication was observed. It con-sisted of bilateral infection, treated with incisionand drainage as well as intravenous antibiotics.Seven minor complications were recorded, includ-ing one desquamation of the nipple-areola com-plex without necrosis (2 percent) and healing bysecondary intention. In six cases, delayed healing(12 percent) occurred at the junction site of theinverted T incision. The postoperative sequelaeincluded a hypochromic areola at 1 year after theprocedure, corrected with tattooing. Three hyper-trophic scars in the lateral part of the horizontalscar were observed.

Patients were asked about their overall satis-faction 1 year following surgery. Thirty-seven pa-tients evaluated their results as “very good” (74percent), nine as “good” (18 percent), and four as“acceptable” (8 percent). There were no resultsassessed as “poor.” When asked about their chiefcomplaint, four patients reported insufficientbreast reduction, despite a functional improve-ment in their daily life (8 percent). Forty-six

percent of the patients found that their backpain had totally resolved versus 54 percent whohad partial resolution but significantly improve-ment. Figures 8 through 10 illustrate the possi-ble results accomplished with the technique de-scribed above.

DISCUSSIONWith the introduction of deepithelialization of

the nipple-areola complex bearing pedicle, de-scribed by Schwartzmann in 1930, and the con-servative breast reduction techniques, the indica-tions for free nipple graft mammaplasty havedecreased significantly. The main indication forfree nipple-areola complex graft remains severegigantomastia. Inferior pedicle and McKissocktechniques remain widely used not only in gi-gantomastia, but also in classic reductionmammaplasty.15,16

The breast reduction with a posterosuperiorpedicle, as described above, seems to be a reli-able and versatile alternative in breast reduc-tion, especially in gigantomastia, eliminatingthe need for free nipple graft, regardless of theweight and ptosis of the breast. Nevertheless,some key elements should be analyzed preciselybefore surgery: age, previous medical history,cause of gigantomastia, smoking habits, qualityof the breast skin, histological component of themammary gland (glandular or adipose), degreeof ptosis, and width of the chest wall. The pres-ence of symmastia, position of the inframam-mary fold, and presence of lateral thoracic ex-tension of the breast should also be taken intoconsideration. These elements do not changethe choice of the surgical technique but allow anadjustment of the preoperative markings withspecial attention to the vascular supply of thenipple-areola complex.

With the development of the reduction mam-maplasty techniques, based on the deepithelial-ized dermoglandular nipple-areola complex–bearing pedicle, three important componentshave been identified: (1) the vascular supply of thenipple-areola complex, (2) the breast shape, and(3) scars left on the breast. Reduction mamma-plasty can be considered a safe procedure from avascular standpoint. The most important criterionis the shape of the breast, which is determined bythe way that the glandular resection is performed.With the introduction of the key-hole model (withor without a predefined areolar incision) andwedge glandular resection, satisfactory aestheticshape of the breast was achieved.24,25 More re-cently, the focus has placed on reducing the

Table 2. Postoperative Results and Details about theSurgical Procedure

Characteristic Value (%)

Follow-up period (mo)Mean 16Range 13–23

Duration of surgery (hr)Mean 2Range 1.50–2.30

Length of hospital stay (days)Mean 2.3Range 2–4

Average amount of breast tissue removed (g)Mean 1231Range 1000–2500

Major complicationsBilateral infection 1 (2)

Minor complicationsDelayed healing 6 (12)Areola desquamation 1 (2)


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length of the scars—the concept of the large in-verted T pattern was followed by J or L scars,26,27passing through the short inverted T,28 and end-ing with the vertical scar mammaplasty.29,30 In ouropinion, the inframammary scar is not an issue aslong as it is located within the inframammary foldand maximal breast projection area. Furthermore,the shape of the reduced breast should not becompromised to shorten the scars.

In gigantomastia, large volumes are usuallyassociated with ptosis, axillary extensions, and hol-lowness of the upper breast pole. However, thevascular supply to the breast remains principallyunmodified, although the blood vessels arestretched down, following the hypertrophic and

ptotic breast. Because of the increased sternalnotch-to-nipple distance, the vascular safety of thenipple-areola complex remains a primary con-cern. Reduction mammaplasties following the in-ferior, superior, superomedial or lateral pediclemodels provide adequate blood supply to the nip-ple-areola complex in cases of reduction mamma-plasty in “normal-sized” breasts, but might not in-clude sufficient arterial flow to the nipple-areolacomplex in cases of gigantomastia. To render thistechnique applicable to gigantomastia, we de-cided to combine the superior pedicle techniquewith the central mound technique (posteriorpedicle).31 When the breast is largely ptotic underthe inframammary fold, all vascular branches have

Fig. 8. Photographs of a 58-year-old woman with gigantomastia and breast asymmetry obtained (above)preoperatively (frontal and oblique views) before resection of 1650 g from the right and 1100 g from the leftbreast. (Below) Result at 2 years (frontal and oblique views).


39

a vertical direction and there is no need to use asuperomedial or superolateral pedicle. In thesecases, the wide superior pedicle receives bloodsupply from perforators of the internal mammaryartery,32 the lateral thoracic artery, and branchesof the thoracoacromial artery. However, the pres-ervation of the perforating branches of the fourthand fifth anterior intercostal artery enhances thevascularization to the breast parenchyma and nip-ple-areola complex.22 There is no need to dissectthe fourth and fifth intercostal perforators. Theirpreservation can be obtained by simply avoidingany dissection over the pectoralis major muscle orcarefully undermining over the inferior part of thepectoralis major muscle and digital underminingin its upper part, so that Würinger’s septum is

preserved. Thus, the perforating branches of theanterior intercostal artery can be safely respected,and will additionally augment the vascularizationto the breast parenchyma and nipple-areola com-plex through the posterior pedicle. The mammarygland maintains its posterior attachments, includ-ing Würinger’s septum. The posterior pedicle canalso be designed in combination with either aninferior or superior pedicle. Thus, the techniquecan be regarded as a combination of the centralmound and the superior pedicle techniques.These different issues make the procedure simpleand relatively fast (can be performed over 2 to 2.5hours’ operating time).

The original technique, based on the horizon-tal septum, was proposed by Würinger in 1999.33

Fig. 9. Photographs of a 42-year-old woman obtained (above) preoperatively (frontal and lateral) before re-section of 1600 g from the right and 1720 g from the left breast. Note the hollowness of the upper pole of thebreast and descent of the whole breast parenchyma below the inframammary fold. (Below) Result at 2 years(frontal and lateral views).


40

This central pedicle technique is entirely based onthe perforators within the horizontal septum.22 Inher series of 42 patients the average amount ofresected breast tissue was 712 g (range, 250 to2100 g). The good results and low complicationsrate in her series showed the reliability of thistechnique, which seems safe even in very largeresections. However, the few cases of large resec-tions in this series (disparity of cases) seem notsufficient to conclude if this technique could beregularly used in gigantomastia cases and we donot have any experience with it.

In a recent study Hamdi et al. described atechnique for reduction mammaplasty on a su-peromedial or superolateral pedicle, based on

Würinger’s septum.34 The results of Hamdi et al.confirm the important role of the horizontal sep-tum for the vascularization of the nipple and are-ola. However, they design the pedicle either on alateral or medial base. In this way blood supplyfrom the lateral thoracic (superolateral pedicle)and internal mammary artery (superomedial pedi-cle) is included in the pedicle in addition to theblood supply from Würinger’s septum (intercostalperforators).34 In our technique a superior pediclealong with the preservation of the horizontal sep-tum is used. In this way, as the pedicle is wide andlong and descends below the inframammary fold,blood supply to the nipple-areola complex comesfrom the thoracoacromial, lateral thoracic, and

Fig. 10. Photographs of a 39-year-old woman obtained (above) preoperatively (frontal and oblique views)before resection of 1480 g from the right and 1530 g from the left breast. Note the hollowness of the upperpole of the breast and descent of the whole breast parenchyma below the inframammary fold. (Below) Resultat 1 year (frontal and oblique views).


41

internal mammary arteries. This blood supply isenhanced by the inclusion of the intercostal per-forators (horizontal septum). In addition, we pre-serve the 2:1 length-to-width pedicle ratio, whichalso enhances the blood supply to the areola.Hamdi et al. also seem to respect this 2:1 ratio. Incases of excessive ptosis this ratio might not bepreserved, but this would not alter significantly thedesign of the pedicle. However, in their study theaverage amount of breast tissue resected is 658 gper breast which is 1231 g per breast in the studypresented herein.

In our experience, the superior pedicle couldbe plicated without difficulties. This was attribut-able to the thinness of the pedicle distally and thecareful digitoclasy to soften the breast paren-chyma along the pedicle and to dissect enoughspace at the superior pole, to which the breast willglide. In medially or laterally based pedicles, thepedicle is rather rotated than plicated, which canbe an additional advantage but may cause torsionof the nipple-areola complex–bearing pedicle.

The limited undermining between gland andskin decreases the risk of vascular compromise ofthe breast tissue and possible cytosteatonecrosis.Furthermore, the sutures, placed to fix the glandmedially (glandulopexy), are used to decrease ten-sion on the scars, rather than to determine a long-term breast shape.

All patients reported good recovery of nipple-areola complex sensitivity at 1 year even thoughthis was not among the studied criteria. The in-nervation of the nipple-areola complex is pro-vided by the fourth intercostal nerve, which runsclose to the anterior intercostal arterial supply.35As a result, the preservation of the perforatorsfrom the anterior intercostal arteries would sparethe corresponding sensitive nerves in all types ofbreast reduction, thus respecting the sensitivity ofthe nipple-areola complex. This was reported alsoby Würinger22 and Hamdi.34

The final scars in cases with gigantomastia areinverted T scars. The inframammary scar neverexceeded the width of the reduced breast and thusremain “hidden” in the inframammary fold. Thelength of this scar was reduced whenever possible.

The complication rate in this series remainslow, with no total nipple-areola loss and one caseof superficial epidermolysis. We noted delayedhealing in 12 percent of the cases at the junctionof the inverted T, which is less than other reportedresults, but not significantly different.17,30,36 Themain patient complaint in this study was the in-sufficient reduction, which was observed in casesof juvenile gigantomastia and was not attributable

to a recurrence of the gigantomastia.37,38 Finally, inaddition to the free nipple graft, inferior pedicle,or McKissock techniques, the posterosuperiorpedicle technique represents another useful andsafe option in gigantomastia breast reduction.32,39

CONCLUSIONSThe posterosuperior pedicle for breast reduc-

tion is a reproducible and versatile technique. Thepreservation of the anterior intercostal artery per-forators enhances the reliability of the vascularsupply to the superior pedicle. This minimally in-vasive subglandular dissection renders the proce-dure safe and reliable in cases with gigantomastia.

Ali Mojallal, M.D.Department of Plastic, Reconstructive and Aesthetic

SurgeryEdouard Herriot HospitalUniversity of Lyon-France

5 Place d’Arsonval 69437 Lyon, Cedex 03, [email protected]

ACKNOWLEDGMENTSThe authors thank Alexandra Hernandez, M.A.,

from Gory Details Illustration for help in preparing theartwork for this article.

REFERENCES1. Bricout N. Hypertrophie et ptose. In: Chirurgie du Sein. 1st ed.

Paris: Springer-Verlag; 1996:73–84.2. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia: A

classification and review of the literature. J Plast ReconstrAesthet Surg. 2008;61:493–502.

3. Sakai Y, Wakamatsu S, Ono K, Kumagai N. Gigantomastiainduced by bucillamine. Ann Plast Surg. 2002;49:193–195.

4. Scott EHM. Hypertrophy of the breast, possibly related tomedication: A case report. S Afr Med J. 1970;44:449–450.

5. Cerveli V, Orlando G, Giudiceandre F, et al. Gigantomastiaand breast lumps in a kidney transplant recipient. TransplantProc. 1999;31:3224–3225.

6. Jackson IT, Bayramicli M, Gupta M, Yavuzer R. Importanceof the pedicle length measurement in reduction mamma-plasty. Plast Reconstr Surg. 1999;104:398–400.

7. Thorek M. Possibilities in the reconstruction of the humanform 1922. Aesthetic Plast Surg. 1989;13:55–58.

8. Oneal RM, Goldstein JA, Rohrich R, Izenberg PH, PollockRA. Reduction mammoplasty with free-nipple transplanta-tion: Indications and technical refinements. Ann Plast Surg.1991;26:117–121.

9. Bardot J, Samson P, Aubert JP, Magalon G. Reduction mam-maplasty with free nipple: Apropos of 5 cases (in French).Ann Chir Plast Esthet. 1995;40:77–82.

10. Robertson DC. The technique of inferior flap mammaplasty.Plast Reconstr Surg. 1967;40:372–377.

11. Arons MS. Reduction of very large breasts: The inferior flaptechnique of Robertson. Br J Plast Surg. 1976;29:137–141.

12. Koger KE, Sunde D, Press BH, Hovey LM. Reduction mam-maplasty for gigantomastia using inferiorly based pedicleand free nipple transplantation. Ann Plast Surg. 1994;33:561–564.


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13. Neuprez A, Haykal S, Calteux N. The use of an inferiordermo-glandular flap in Thorek’s technique, based on aseries of 21 cases (in French). Ann Chir Plast Esthet. 1999;44:231–237.

14. Mojallal A, Comparin JP, Voulliaume D, Chichery A, PapaliaI, Foyatier JL. Reduction mammaplasty using superior pedi-cle in macromastia (in French). Ann Chir Plast Esthet. 2005;50:118–126.

15. Robbins TH. A reduction mammaplasty with the areola-nip-ple based on an inferior dermal pedicle. Plast Reconstr Surg.1977;59:64–67.

16. McKissock PK. Reduction mammaplasty with a vertical der-mal flap. Plast Reconstr Surg. 1972;49:245–252.

17. Landau AG, Hudson DA. Choosing the superomedial pedi-cle for reduction mammaplasty in gigantomastia. Plast Re-constr Surg. 2008;121:735–739.

18. Danino AM, Lile A, Moutel G, Herve C, Malka G. Visualdocumentation of oral consent: A new method of informedconsent before major gigantomastia reduction for an illit-erate population. Plast Reconstr Surg. 2006;117:1370–1371.

19. Nakajima H, Imanishi N, Aiso S. Arterial anatomy of thenipple-areola complex. Plast Reconstr Surg. 1995;96:843–845.

20. van Deventer PV. The blood supply to the nipple-areolacomplex of the human mammary gland. Aesthetic Plast Surg.2004;27:393–398.

21. O’Dey D, Prescher A, Pallua N. Vascular reliability of nipple-areola complex-bearing pedicles: An anatomical microdis-section study. Plast Reconstr Surg. 2007;119:1167–1177.

22. Würinger E, Mader N, Posch E, Holle J. Nerve and vesselsupplying ligamentous suspension of the mammary gland.Plast Reconstr Surg. 1998;101:1486–1493.

23. Biesenberger H. Eine neue Methode der Mammaplastik.Zentralbl Chir. 1928;55:2382–2387.

24. Pitanguy I. A new technic of plastic surgery of the breast:Study of 245 consecutive cases and presentation of a personaltechnic (in French). Ann Chir Plast. 1962;7:199–208.

25. Weiner DL, Aiache AE, Silver L, Tittiranonda T. A singledermal pedicle for nipple transposition in subcutaneousmastectomy, reduction mammaplasty, or mastopexy. PlastReconstr Surg. 1973;51:115–120.

26. Baux S, Mimoun M, Zumer L, Nivesse D. Reduction mam-moplasty with a J-shaped scar (the Jean-Sauveur Elbaz tech-

nic): Review of 125 cases (in French). Ann Chir Plast Esthet.1990;35:123–127.

27. Bozola AR. Breast reduction with short L scar. Plast ReconstrSurg. 1990;85:728–738.

28. Ramirez OM. Reduction mammaplasty with the “owl” inci-sion and no undermining. Plast Reconstr Surg. 2002;109:512–522; discussion 523–524.

29. Lejour M. Vertical mammaplasty. Plast Reconstr Surg. 1993;92:985–986.

30. Azzam C, De Mey A. Vertical scar mammaplasty in giganto-mastia: Retrospective study of 115 patients treated using themodified lejour technique. Aesthetic Plast Surg. 2007;31:294–298.

31. Rodier-Bruant C, Wilk A, Rosenstiel M, Nisand G, Meyer C.Does the choice of mammoplasty pedicle influence the shapeof the reduced-sized breast? (in French). Ann Chir Plast Esthet.1995;40:404–411.

32. Ricbourg B. Applied anatomy of the breast: Blood supply andinnervation (in French). Ann Chir Plast Esthet. 1992;37:603–620.

33. Würinger E. Refinement of the central pedicle breast reduc-tion by application of the ligamentous suspension. Plast Re-constr Surg. 1999;103:1400–1410.

34. Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, MonstreyS. Septum-based mammaplasty: A surgical technique basedon Würinger’s septum for breast reduction. Plast ReconstrSurg. 2009;123:443–454.

35. Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of thenipple-areola complex: An anatomic study. Plast ReconstrSurg. 2000;105:905–909.

36. Lacerna M, Spears J, Mitra A, et al. Avoiding free nipple graftsduring reduction mammaplasty in patients with gigantomas-tia. Ann Plast Surg. 2005;55:21–24; discussion 24.

37. Kulkarni D, Beechey-Newman N, Hamed H, Fentiman IS.Gigantomastia: A problem of local recurrence. Breast 2006;15:100–102.

38. Boyce SW, Hoffman PG Jr, Mathes SJ. Recurrent macromas-tia after subcutaneous mastectomy. Ann Plast Surg. 1984;13:511–518.

39. Datta G, Carlucci S. Selective breast reduction: A personalapproach with a central-superior pedicle. Plast Reconstr Surg.2009;123:433–442.


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BREAST...hypertrophy, with breast weight greater than 1500 g, as opposed to a mean breast weight,inFrance,of300g.Itisoftenseeninobese patients. Gigantomastia can be idiopathic with