Enhancing pedicle safety in mastopexy and breast reduction procedures: the posteroinferomedial pedicle, retaining the medial vertical ligament of Würinger.
BACKGROUND
Nipple necrosis, a potential postoperative complication of breast surgery procedures, should be avoided. Because of the great variation in the blood supply to the nipple, it is advisable to include as many arteries in the pedicle as possible. According to the literature, the perforators of the internal thoracic artery are the most constant and reliable sources of blood to the nipple-areola complex. It is also supplied by the lateral thoracic artery and the anterior intercostal arteries. If two of the above-mentioned main vessel branches are included in the pedicle, the vascular supply to the breast will be more reliable. According to the anatomical studies of Würinger and van Deventer, we can safely include the dual blood supply to the nipple-areola complex.


METHODS
In the authors' technique, a pedicle is raised that includes the horizontal septum and the medial vertical ligament of the breast (i.e., inferior and superomedial pedicles), but with the breast tissue remaining attached to the pectoral fascia. The second, third, and fourth perforators of the internal thoracic artery are found in the medial vertical ligament, and the inferior mammary branches of the anterior intercostal arteries are in the horizontal septum. The authors have performed this technique in 106 consecutive patients (211 breasts) between 2001 and 2009.


RESULTS
Good results regarding breast shape, nipple projection, and upper breast fullness were obtained.


CONCLUSIONS
The posteroinferomedial pedicle technique is safe and versatile and can be used with a periareolar, vertical scar, or inverted-T skin approach. The technique is easy to perform and has a short learning curve.
van Deventer
Petrus V
PV
Bellville, South Africa From the Division of Plastic and Reconstructive Surgery, Faculty of Health Sciences, University of Stellenbosch.
Graewe
Frank R
FR
D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008022:Ligaments; D016462:Mammaplasty / Q000379:methods*; D008875:Middle Aged; D009558:Nipples; D013524:Surgical Flaps / Q000098:blood supply*; D055815:Young Adult
Manchot C. Die Hautartieren des menslichen Korpers. Leipzig: Vogel; 1889.
Marcus GH. Untersuchungen uber die arterielle Blutversorgung der Mammila. Arch Klin Chir. 1934;179:361–369.
Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg. 1986;39:287–299.
van Deventer PV. The blood supply to the nipple-areola complex of the human mammary gland. Aesthetic Plast Surg. 2004;27:393–398.
van Deventer PV, Page J, Graewe FR. The safety of pedicles in mastopexy and breast reduction procedures. Aesthetic Plast Surg. 2008;32:307–312.
Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg. 1988;101:1486–1493.
Wueringer E, Tschabitscher M. New aspects of the topographical anatomy of the mammary gland regarding its neurovascular supply along a regular ligamentous suspension. Eur J Morphol. 2004:40:181–189.
O'Dey DM, Pallua N, Perscher A. Vascular reliability of nipple-areola complex-bearing pedicles: An anatomical microdissection study. Plast Reconstr Surg. 2007;119:1167–1177.
Blondeel PN, Hamdi M, Van de Sijpe KA, Van Landuyt K, Thiessen FE, Monstrey S. The latero-central glandular pedicle technique for breast reduction. Br J Plast Surg. 2003;56:348–359.
Reid CD, Taylor GI. The vascular territory of the acromiothoracic axis. Br J Plast Surg. 1984;37:194–212.
Hamdi M, Van Landuyt K, Tonnard P, Verpaele A, Monstrey S. Septum-based mammaplasty: A surgical technique based on Würinger's septum for breast reduction. Plast Reconstr Surg. 2009;123:443–454.