Moufarrege Total Posterior Pedicle Breast Reduction
Mammaplasty has improved so much over time that this operation currently boasts one of the greatest numbers of surgical techniques. Authors have introduced certain modifications for surgical improvements, leading to a gradual development of techniques reminiscent of the evolution of species. However, this evolution introduced some avant-garde techniques that were eventually abandoned and condemned. Because they were used without an associated safety procedure, the techniques were deemed dangerous and had the potential for various complications. 
The purpose of mammary reduction is to decrease breast volume. With it, in the past, came the aesthetic need to add a grafted nipple in a trompe l’oeil fashion. That technique remains in use in some surgical centers, but it has fortunately been replaced in most of them by reductions with transposition of the nipple, with consequent conservation of the nipple as a flap based on a vascular pedicle. The quality of a transposed nipple is clearly superior to that of a grafted one.
A large pedicle was not required to keep the nipple alive; often, but not always, a thin strip of subcutaneous fat was sufficient. If the nipple survived the ischemia of fragile transposition, it remained inert, congestive for a long while, and insensitive, with its neighboring position being the only relation to underlying tissues. Innovators, attempting to increase the safety of the nipple by thickening its pedicle, recommended increasingly thicker fatty flaps. Survival of the nipple increased, yet the torsion of the pedicle, necessary for the new positioning of this important complex, often produced surprises.
These pedicles were always of superior origin (at the 12-, 10-, or 2-o’clock position), lateral origin (at the 3- or 9-o’clock position), or bifid but they were never of inferior origin. Resections were performed in the inferior quadrant of the breast, automatically cutting all bridges for a glandular pedicle of that quadrant. Because the transposition was always made toward the top, these glandular pedicles could not be very thick; if they were, displacement and torsion would be more damaging (see image below).
The advantage of creating a nipple of superior quality by adding a glandular bridge to the fatty pedicle was clear. Surgeons who were convinced of that principle also quickly understood that a thick pedicle cannot be soft enough to allow displacement of the nipple in all directions and without any constraint at will if that pedicle was superior, oblique, or lateral. They also understood that such a mobile pedicle cannot originate from close surrounding tissues to avoid mechanical constraints with mobilization of the nipple. Thus, it now appears obvious that such a pedicle should originate somewhere in the mass of breast tissue, allowing its displacement in all directions. This eliminates all limitations to the mobilization of the nipple-areola complex.
In 1971, McKissock improved the pedicle of the nipple-areola complex by choosing 2 bridges. Between them, the inferior is quite large and connects the nipple to deep glandular tissue to allow vascularity of the nipple by perforating vessels emanating from the pectoralis major. Contrary to the previous techniques, McKissock’s technique based the nipple on a mass of the breast gland that could represent 10-15% of the total mass of the remaining breast after reduction (see section A of the image below).
Only a Biesenberger reduction based the nipple on a larger mass of the remaining breast; unfortunately, the Biesenberger method had too many problems inherent in the detachment of the breast from the pectoralis major, consequently causing interruption of the perforating vessels and a high rate of breast tissue necrosis. Thus, this type of reduction was abandoned.
In 1976, Robbins, carrying on McKissock’s work, based the nipple on a simple inferior pedicle, probably a little larger than McKissock’s.  Mammary mass in connection with the nipple had to represent 15-25% of the remaining mammary volume (see section B of the image above).
Since 1979, the author (Richard Moufarrege) has used 100% of the remaining gland as vascular support for the nipple-areola complex.  This pedicle initially was in a posterior and inferior position, but eventually it occupied the entire height of the gland. Care is always taken to include 100% of the remaining breast. This is the total dermoglandular posterior pedicle mammoplasty (see section C of the image above).
Breast surgery, either lifting or reduction, consists of more than displacing an inert mass or simply reducing as in other resection surgery on undesirable tissue. Indeed, one must also be greatly concerned with how the breast will appear afterward and with the other functions of the remaining breast tissue. Reducing the breast tissue and not taking care of the nipple, its position, and its relationship with the remaining volume of the breast has already been suggested by some authors, but, in the author’s opinion, these are inelegant gestures that discount the talent of plastic surgeons and their potential to achieve artful results.
The surgeon must preserve the most important functions of a woman’s breast, such as the quality of sensation of the nipple, contractility, and breastfeeding ability. Plastic surgeons also must be very demanding in terms of shape, proportion, volume, and scarring. Obtaining a nicely shaped breast on a normally built woman with minimal scars; harmonious features; and a well-placed, sensitive, contractile nipple is now the standard in mammaplasty.
The origin of hypertrophies is multiple. Most breast hypertrophies do not have a precise etiology but seem to occur more frequently in some families. Hypomastia also seems to occur more frequently in some families. Apart from this majority of unexplained hypertrophies, a large number of hormones act on breast development, either by enlarging them or by reducing them. Among these are estrogen, progesterone, testosterone, glucocorticoids, insulin, prolactin, growth hormone, thyroid hormone, and oxytocin.
Removed breast tissue is always examined in pathology in order to recognize the presence of any cancerous cells. If cancerous cells are present, the anatomical position of such tissues can be more easily evaluated in this one-block resection, which allows the oncological surgeon to determine the appropriate treatment in each individual case.
Some fibroadenomas are discovered without any clinical consequences on the future of the breast.
This technique is performed openly on a breast completely stripped on its anterior aspect. Resection is performed at the periphery, and the entire remaining gland is in direct contact with the nipple and acts as the pedicle. Thus, the pedicle of the nipple-areola complex is composed of the entire remaining breast that extends from the lowest to the highest limit of the breast, hence the term total pedicle. This characteristic lends the technique of the total pedicle all its other peculiarities and advantages, described below.
Breast reduction is meant to treat the problem of very large breasts causing physical and physiological discomfort and pain. These problems can be so important and significant that, in some medical systems, their treatment is covered by medical insurance when the removed breast is larger than a certain average volume and weight.
The breast extends from the second to the seventh rib. Its horizontal limits are the sternal bone medially and the frontal axillary line laterally. The breast glandular tissue is primarily vascularized by the perforating vessels arising from the internal mammary artery and intercostal arteries. According to different authors, this posterior vascularization provides 70-80% of the breast blood supply. This has been the very determinant factor in the choice of using a total posterior pedicle mammaplasty.
In the author’s point of view, innervation of the nipple is both the first and the most important issue. It originates from the intercostal nerves, mainly the fourth, fifth, and sixth, which run along the aponeurosis of the chest muscles and, once in the central area of the breast, proceed ventrally through the breast tissue to the nipple-areola complex. The conservation of these nerves allows the total posterior pedicle to preserve the erogenic sensation of the nipple-areola complex (see image below).
The second nervous system is the one running in the subcutaneous tissue in the surrounding areas of the nipple-areola complex and gives the nipple the tactile sensation but not the erogenic one. This last one is responsible of the recuperation of the tactile sensation of the nipple but has no effect on the recovery of the erogenic sensitivity.
For more information about the relevant anatomy, see Breast Anatomy.
In the author’s opinion, severe obesity is a contraindication for the realization of a nice breast.
Patients should have completely stopped smoking 3 months before surgery and should not smoke during the 3 months after mammaplasty.
The author recommends that patients lose excess of weight for many reasons, among which are to be healthier for the perioperative period, to have less scarring owing to shorter incisions, and to have an acceptable ratio between the new breast volume and the abdomen volume.
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Richard J Moufarrège, MD, FRCSC Professor, Department of Plastic Surgery, Hôtel-Dieu, University of Montreal, Canada
Richard J Moufarrège, MD, FRCSC is a member of the following medical societies: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association, Quebec Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children’s Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center
James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress
Disclosure: Nothing to disclose.
Geoffrey L Robb, MD, FACS Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center
Geoffrey L Robb, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Society of Plastic Surgeons, American College of Surgeons, American Society of Maxillofacial Surgeons, American Society for Reconstructive Microsurgery, Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous editor Saleh M Shenaq, MD†, to the development and writing of this article.
Moufarrege Total Posterior Pedicle Breast Reduction
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