Evaluation of the superomedial pedicle breast reduction technique by measuring nipple areola complex projection: a prospective analysis of a cross-sectional study

Introduction

Breast reduction is a standard aesthetic and reconstructive plastic surgery operation associated with improved psychological and physical outcomes in patients with symptomatic macromastia (1-5). The techniques for performing reduction mammoplasty vary widely among surgeons, with much of this variation attributed to differences in nipple-areola complex (NAC) pedicle approaches (6). Achieving optimal NAC location and projection is critical to the operation’s success, though sustained projection after breast reduction often proves challenging (7,8). Previous studies have identified NAC projection as a critical determinant of postoperative patient satisfaction (9).

Various measurement protocols and preoperative marking schemes have been developed to guide NAC placement. While measures referencing the inframammary fold or upper breast border are commonly used, final positioning ultimately depends on surgeon experience, comfort, and individualized patient characteristics. Traditionally, the inferior pedicle technique has been considered to provide the most reliable vascularity and remains the most commonly used approach (10). This inferior pedicle technique with inverted T closure was popular due to its ability to maintain NAC sensation and lactation. It was also, unfortunately, associated with pseudoptosis or “bottoming out” that was, at the time, thought to be an effect of gravity over time that was unsolvable (11). While vertical techniques utilizing a superior pedicle were popularized in Europe and South America to reduce scar burden, these superior pedicles were difficult to inset, particularly with larger reductions (12-14). The superomedial pedicle technique (14-16), initially associated with an attempt to improve nipple viability, has more recently demonstrated equivalent safety outcomes and improved cosmetic appearance in comparative studies (17-21). In theory, the superomedial technique reduces pseudoptosis due to rotation of the NAC superiorly and bolstering of the NAC with inferior breast tissue. This aesthetic effect of NAC projection is a key consideration during breast reduction as described by Mugea (22). In terms of the specific measurements for the NAC, however, little work has been done to characterize the relationship between the superomedial technique and projection following reduction mammoplasty (23).

To better understand the relationship between operative technique and breast projection, we designed this prospective study to assess specific NAC projection and location measurements in patients undergoing superomedial pedicle reduction mammaplasty (24). We hypothesized that projection could be improved through the characteristic shortening of the axilla-to-nipple distance along the lateral chest wall, specific to the superomedial pedicle technique. We present this article in accordance with the STROBE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-12/rc).

Methods

We conducted a prospective, cross-sectional study of patients undergoing reduction mammaplasty performed by a single surgeon using a superomedial technique at the University of Alabama at Birmingham between September 2019 and January 2021. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of University of Alabama at Birmingham (No. 141105005). Informed consent was obtained from patients for inclusion of patient images and measurements.

All adult females undergoing reduction mammaplasty for any indication were considered for inclusion. Patients with a history of breast cancer or those undergoing unilateral reduction were excluded.

Prospective measurements were obtained preoperatively and then postoperatively at approximately 2 months. The nipple angle is measured placing the center of a goniometer on the lateral chest wall at the anterior axillary line. The beam or zero degree of the goniometer is placed in line with the bottom aspect of the breast and then the angle is measured to the NAC. A second measurement is then taken in line with the nipple location on the lateral chest wall and the distance is measured from the lateral chest wall up to the axilla. All measurements were taken in the standing position and were performed independently by a single surgeon to ensure measurement robustness (Figure 1).

Figure 1 Preoperative images of a patient undergoing superomedial breast reduction with measurements of interest. (A) General breast measurements and markings preoperatively. (B) Example image of NAC angle measurement. (C) Example image of lateral chest wall to axilla measurement. NAC, nipple-areola complex.

The technique, in brief, begins with de-epithelialization of a superomedial area around the nipple and corresponding to the superomedial pedicle to be used. The pedicle is suspended to the pectoralis fascia with a 2-0 bidirectional barbed suture. Vertical cuts inferior to the NAC are made with intention to remove tissue from the inferior and lateral portions of the breast. The NAC is rotated on its pedicle superiorly and the vertical incision is closed. Puckering at the bottom of the vertical incision is corrected with a. short transverse incision, ultimately creating an inverted T-style scar with a triangle in the center of the inframammary fold. Closure is first approximated with staples, tailored, and closed in multi-layer, interrupted fashion (14,25).

Statistical analysis

Statistical analysis using paired Student’s t-test was then used to compare preoperative and postoperative findings. All statistics and figures were performed in R with statistical significance achieved for P<0.05 using two-sided test.

Results

A total of 18 patients (36 breasts for measurement) underwent reduction mammaplasty during the specified timeframe and were included in the study (Figure 2). Ten of these patients (20 breasts) were additionally evaluated for measurements of NAC position relative to the lateral chest wall.

Figure 2 Preoperative and postoperative comparative images of two patients after having undergone superomedial breast reduction mammoplasty. (A) Preoperative images. (B) Postoperative images of the same patient. (C) Side view of pre- and postoperative images of a separate patient.

For all 36 breast measurements, the average preoperative angle was 9.5±8.87 degrees; with the postoperative angle average increasing to 27.4±3.52 degrees, for an average difference from preoperative to postoperative being 17.97±9.63 degrees (Figure 3, P<0.001).

Figure 3 Preoperative and postoperative NAC angle measurements. NAC, nipple-areola complex.

The average preoperative distance from the lateral chest wall was 16.41±3.73 cm, with an average postoperative distance of 9.94±1.87 cm (Figure 4, P<0.001). The average difference between preoperative and postoperative measurements was a reduction of 6.47±3.37 cm.

Figure 4 Preoperative and postoperative NAC measurements from the lateral chest wall to the axilla. NAC, nipple-areola complex.

Discussion

Our findings demonstrate that the superomedial technique consistently achieves improvement in NAC projection with associated shortening of lateral chest wall distance. Despite numerous studies documenting psychological and physical benefits of reduction mammoplasty for women with macromastia, along with improvements in overall quality of life scores, there is limited data to guide anticipated measurement changes between different techniques for achieving specific aesthetic outcomes (19-21). With these findings, patients can be made aware of the geometric changes that may be expected after a superomedial breast reduction. In addition, these findings support the notion that the superomedial technique improves NAC projection as a key marker in terms of purported ideal breast configuration (22).

This study provides objective, geometric data establishing a baseline for measurement of NAC projection in reduction mammaplasty and clearly demonstrates an improvement in these parameters with the superomedial technique.

The primary limitations of this study include its non-randomized design and the possibility that preoperative patient factors contributed to the favorable outcomes observed. Furthermore, while we demonstrated significant measurement differences pre- and post-surgery, overall patient satisfaction was not assessed. Given that aesthetic priorities may vary among patients, it is possible that these specific changes may not be desirable for all patients. In addition, the current sample size is relatively small and would benefit from increased sampling to improve robustness and generalizability.

Still, our data may provide valuable insight for patients exploring breast reduction options and guidance regarding expected postoperative outcomes. The simultaneous improvement in nipple angle from an average of 9.5 to 27.4 degrees and shortening distance between the axilla and the NAC level at the lateral chest wall contributes to an aesthetic outcome resistant to pseudoptosis.

These data can be used for comparative analysis of other techniques, guide internal quality improvement initiatives, and facilitate patient communication regarding anticipated aesthetic outcomes. In addition, having these objective measurements makes aesthetic outcomes more predictable and reproducible which, combined with a comparative complication rate, suggests the superomedial approach may be an underutilized technique for reduction mammaplasty. Future studies should evaluate the long-term maintenance of this improved NAC projection and test associations between specific geometric measurements with overall patient satisfaction.

Conclusions

In conclusion, we have defined specific, geometric outcomes related to the superomedial technique for reduction mammaplasty, demonstrating significant improvement in NAC projection and location. Based on these findings, we hypothesize for future study that these improvements will lead to enhanced aesthetic outcomes and complement the established psychological and physical benefit for patients with macromastia.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-12/rc

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-12/dss

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-12/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-12/coif). S.C. serves as an unpaid editorial board member of AME Surgical Journal from April 2025 to March 2027. She has internal funding on a skin cancer margins grant and has submitted two grants but none are related to this paper. She is a paid medical consultant for Avita Medical and presented at one of their meetings and this is not related to this paper. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of University of Alabama at Birmingham (No. 141105005).Informed consent was obtained from patients for inclusion of patient images and measurements.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gonzalez F, Walton RL, Shafer B, et al. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg 1993;91:1270-6. [Crossref] [PubMed]
2. Boschert MT, Barone CM, Puckett CL. Outcome analysis of reduction mammaplasty. Plast Reconstr Surg 1996;98:451-4. [Crossref] [PubMed]
3. Setälä L, Papp A, Joukainen S, et al. Obesity and complications in breast reduction surgery: are restrictions justified? J Plast Reconstr Aesthet Surg 2009;62:195-9. [Crossref] [PubMed]
4. Pérez-Panzano E, Gascón-Catalán A, Sousa-Domínguez R, et al. Reduction mammaplasty improves levels of anxiety, depression and body image satisfaction in patients with symptomatic macromastia in the short and long term. J Psychosom Obstet Gynaecol 2017;38:268-75. [Crossref] [PubMed]
5. Rogliani M, Gentile P, Labardi L, et al. Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg 2009;62:1647-9. [Crossref] [PubMed]
6. Messana F, Grigatti M, Budini V, et al. The McKissock's technique in reduction mammaplasty: A comparative study of outcomes and complications in 211 consecutive patients. Front Surg 2022;9:970381. [Crossref] [PubMed]
7. Casas LA, Byun MY, Depoli PA. Maximizing breast projection after free-nipple-graft reduction mammaplasty. Plast Reconstr Surg 2001;107:955-60. [Crossref] [PubMed]
8. Hudson DA, Geldenhuys S, Duminy F, et al. Another look at breast projection after breast reduction. Aesthetic Plast Surg 2008;32:928-32. [Crossref] [PubMed]
9. Jabor MA, Shayani P, Collins DR Jr, et al. Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg 2002;110:457-63; discussion 464-5. [Crossref] [PubMed]
10. Kerrigan CL, Slezak SS. Evidence-based medicine: reduction mammaplasty. Plast Reconstr Surg 2013;132:1670-83. [Crossref] [PubMed]
11. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg 2002;29:379-91. [Crossref] [PubMed]
12. Lejour M. Vertical mammaplasty as secondary surgery after other techniques. Aesthetic Plast Surg 1997;21:403-7. [Crossref] [PubMed]
13. Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg 1996;97:373-80. [Crossref] [PubMed]
14. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104:748-59; discussion 760-3.
15. Lassus C. Breast reduction: evolution of a technique--a single vertical scar. Aesthetic Plast Surg 1987;11:107-12. [Crossref] [PubMed]
16. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 1994;94:100-14. [Crossref] [PubMed]
17. Finger RE, Vasquez B, Drew GS, et al. Superomedial pedicle technique of reduction mammaplasty. Plast Reconstr Surg 1989;83:471-80. [Crossref] [PubMed]
18. Bostwick J 3rd. Breast reconstruction after mastectomy. Recent advances. Cancer 1990;66:1402-11. [Crossref] [PubMed]
19. Makboul M, Abdelhamid M, Al-Attar G. Long Term Follow up and Patient Satisfaction after Reduction Mammoplasty: Superomedial versus Inferior Pedicle. World J Plast Surg 2017;6:82-7.
20. Kemaloğlu CA, Özocak H. Comparative Outcomes of Inferior Pedicle and Superomedial Pedicle Technique With Wise Pattern Reduction in Gigantomastic Patients. Ann Plast Surg 2018;80:217-22. [Crossref] [PubMed]
21. Lugo LM, Prada M, Kohanzadeh S, et al. Surgical outcomes of gigantomastia breast reduction superomedial pedicle technique: a 12-year retrospective study. Ann Plast Surg 2013;70:533-7. [Crossref] [PubMed]
22. Mugea T. Breast Assessment and Implant Selection Using the TTM Aesthetic Breast Chart. In: Shiffman M, editor. Breast Augmentation: Springer; 2009:85-105.
23. Colohan SM, Massenburg BB, Gougoutas AJ. Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes. Plast Reconstr Surg 2020;146:339e-350e. [Crossref] [PubMed]
24. Smithson MG, Collawn SS, Mousa MS, et al. A Formula for Planning and Predicting Postoperative Mammoplasty Results. Ann Plast Surg 2017;78:S343-6. [Crossref] [PubMed]
25. Spear SL, Davison SP, Ducic I. Superomedial pedicle reduction with short scar. Semin Plast Surg 2004;18:203-10. [Crossref] [PubMed]