Principles for pedicle choice: Avoiding vascular compromise

Reduction mammaplasty remains a procedure with exceedingly high satisfaction for both patient and surgeon alike. A reduction mammaplasty can conceptually be understood as the attempt to achieve three goals: aesthetic appearance, considering the nipple-areolar complex (NAC) position, parenchymal shape, and acceptable scars; viable NAC, which has the normal three-dimensional shape with preserved pigmentation; and sensate NAC with retained lactation. The therapeutic procedures scale with the desired correction, trading safety for degree of correction. As in all plastic surgery, patient selection and patient counseling are critical. Techniques range from suction lipectomy and parenchymal wedge resection, typically for more modest reduction and treatment of pseudoptosis, to pedicle-based techniques, by far the most common form of reduction mammaplasty in North America. As the desired correction exceeds debatable extremes, reduction and free nipple graft offer a reasonable solution that compromises one of the three objectives, while more safely assuring the other two. As in all plastic surgery, exciting new advances in avoiding vascular compromise are always on the horizon.