British
Jorrrnal
of Plastic
Surgery
(1975),
THE SUPEROMEDIAL
By J.
28, 42-45
DERMAL PEDICLE FOR NIPPLE TRANSPOSITION
C. ORLANDO, M.D.,l
and R. H. GUTHRIE, Jr., M.D.
From the Divisions of Plastic Surgery, The New York Hospital-Cornell
The Memorial Sloan-Kettering Cancer Center
Medical Center and
A PRINCIPAL concern in both reduction mammaplasty and dermal mastopexy has been
to find a safe, suitable and technically easy method of transposing the nipple to its new
bed while maintaining viability and normal sensation and obtaining a cosmetically
acceptable result.
The standard method for nipple transposition is that of Skoog (1963) and Strombeck
(1960) where the nipple is carried on a transverse de-epithelialised,
bipedicle flap,
which maintains good nipple sensation and viability. We have found that tension on
nipples thus transposed may be excessive, leading to areolar distortion post-operatively
Several authors have addressed themselves
with nipple inversion and inferior retraction.
to this problem (Strombeck, 1964; Gupta, 1965; McKissock, 1972; Weiner et al., 1973).
Tension can be relieved by dividing either one pedicle (partially or completely)
or the inferior portion of both pedicles. While this may relieve tension on the transposed
nipple, it may also diminish viability.
In an attempt to solve this problem, we have tried the vertical bipedicle flap recommended by McKissock.
Unfortunately,
of 8 nipples transposed in this way, 4
In addition, the de-epithelialisation
of the
were totally anaesthetic post-operatively.
long, inferior pedicle is much too time consuming, and there is some suspicion in our
minds that this long inferior pedicle may be a parasite rather than a contributor of blood
supply at the new nipple site.
FIG. I.
FIG. 2
FIG. I
The outline and extent of the pedicle. The area “A” must be excised at the new nipple site to
facilitate rotation.
FIG. 2.
The nipple and pedicle elevated from the breast tissue.
I Present address: The Hampton Plaza, 300 East Joppa Road, Towson, Maryland 21202.
42
THE
SUI’EROMEDIAL
DERMAL
PEDICLE
FOR
NIPPLE
TRANSPOSITION
33
‘.
’
.I
MEDIA1
FIG. 3
FIG. 3.
FIG. 4
The nipple and pedicle rotated into position.
FIG. 4.
FIG. 5.
A representative
Final closure of the incisrons.
case, pre-operatively
(upper left) and 4 months post-operatively.
BRITISH
44
FIG. 6.
Another representative
We therefore
JOURNAL
OF PLASTIC
case, pre-operatively
SURGERY
(upper left) and 4 months post-operatively.
tried to combine what we felt were the best features of both tech-
niques .
METHOD
The nipple is transposed on a superomedial de-epithelialised pedicle (Fig. I)
which contains a thin layer of subcutaneous tissue to protect the dermal blood supply.
The pedicle is based on the full extent of the medial skin flap (patterned after Wise,
This lateral
1956) and the entire new nipple site except for a small lateral portion.
portion of the new nipple site (A in Fig. I) must be excised to obtain easy mobility in
transposing the nipple. Figures 2 to 4 show the nipple and pedicle being dissected from
the underlying breast tissue and rotated into place. When necessary, the mammary
ducts are divided. On occasion, the lower aspect of the pedicle must be divided from
the medial skin flap for a distance of I to 2 cm to facilitate rotation to the new nipple
site.
DISCUSSION
This method of nipple transposition has been used in 24 breasts in 12 patients
over the past year. Representative cases are shown in Figures 5 and 6. There have been
All patients, with one exception, have retained
no problems with nipple viability.
sensation to pin prick and fine touch. We attribute this to the medial aspect of the dermal
THE
SUPEROMEDIAL
DERMAL
PEDICLE
FOR
NIPPLE
TRANSPOSITION
45
pedicle which carries fibres from the anterior cutaneous branches of the 4th and 5th
intercostal nerves. Weiner et al. describe a single superior dermal pedicle for nipple
transposition with excellent results regarding viability but no mention of sensation.
We feel the superomedial dermal pedicle is superior to the single superior dermal
pedicle, because nipple sensation is retained, and in long pedicles a broader base ensures
better viability.
Jn reduction mammaplasty a lower wedge resection is carried out following transposition. We do not excise a core of tissue from the new nipple site, having found that
this cavity alone has caused nipple retraction due to a lack of bulk support deep to the
nipple. We have found this pedicle equally applicable to dermal mastopexy operations
with similar results.
SUMMARY
A new method for nipple transposition
employing a superomedial dermal pedicle
is described for use in reduction mammaplasty and dermal mastopexy. The advantages
include superior mobility, viability, sensation and normal appearing nipples and areolae.
REFERENCES
S. C. (1965).
A critical review of contemporary
procedures
for mammary
reBritish Journal of Plastic Surgery, IS, 328.
duction.
McKrssoc~,
P. K. (1972).
Reduction
mammaplasty
with a vertical dermal flap.
Plasric
and Recomtmctive Surgery, 49, 245.
SKOUG, T. (1963). A technique
of breast reduction.
Acta Chirurgica Scandinavica, 126,
453.
Mammaplasty:
report
of
a
new
technique
based on the two pedicle
STROMBECK,
J. 0. (1960).
British Journal of Plastic Surgery, 13, 79.
procedure.
STROMBECK, J. 0. (1964).
Reduction
mammaplasty.
In “Modern
Trends
in Plastic
vol. I, edited by Gibson, T., p. 247. London:
Butterworth.
Surgery”,
WEINER, D. L., AIACHE, A. E., SILVER, L. and TITTIRANONDA, T. (1973).
A single dermal
pedicle for nipple transposition
in subcutaneous
mastectomy,
reduction
mammaplasty,
or mastopexy.
Plastic and Recomtructive Surgery, 51, IIS.
A preliminary
report on a method of planning the mammaplasty.
Plastic
WISE, R. J. (1956).
md Reconstructive Surgery, 17, 356.
GUPTA,