The Pedicled Robertson Mammaplasty: Minimization of Complications in Obese Patients With Extreme Macromastia

Abstract

Background

Breast reduction for extreme macromastia in obese patients is a potentially high-risk endeavor. Free nipple grafting as well as a variety of pedicled techniques have been advocated for large reductions in obese patients, but the number of different approaches suggests that no single method is ideal. This paper suggests the Robertson Mammaplasty, an inferior pedicle technique characterized by a curvilinear skin extension onto the pedicle, as a potentially favorable approach to this clinical situation.

Objectives

The author sought to determine the safety of the Pedicled Robertson Mammaplasty for extreme macromastia in obese patients.

Methods

The records of a single surgeon’s practice over a 15-year period were retrospectively reviewed. Inclusion criteria were a Robertson Mammaplasty performed with a >3000-g total resection and a patient weight at least 20% above ideal body weight. Records were reviewed for patient characteristics, operative times, and complications.

Results

The review yielded 34 bilateral reduction patients that met inclusion criteria. The mean resection weight was 1859.2 g per breast, the mean body mass index was 36.4 kg/m², and the mean sternal notch-to-nipple distance was 41.4 cm. Mean operative time was 122 minutes. There were no cases of nipple necrosis and no major complications that required reoperation under general anesthesia. A total 26.4% of patients had minor complications that required either local wound care or small office procedures, and 4.4% received small revisions under local anesthesia.

Conclusions

The Pedicled Robertson Mammaplasty is a fast and safe operation that yields good aesthetic results and a relative minimum of complications in the high-risk group of obese patients with extreme macromastia.

Level of Evidence: 4

The optimal approach to extreme macromastia is by no means a resolved issue. In these patients, the main concern is often safety in that some evidence indicates that complications increase with increasing resection weight.^1-3 To address this concern, there remain advocates for the time-honored free nipple grafting^4,5 as well as advocates for a variety of pedicled techniques. A broad-based inferior pedicle was traditionally the standard pedicled approach to extreme macromastia,⁶ but in recent years superomedial techniques have been increasingly reported.^7,8 Other workers have advocated customized pedicles based on ultrasonographically demonstrated vascular anatomy,⁹ a posterosuperior pedicle,¹⁰ and even “short scar” ^11-13 techniques for extreme macromastia. Although good results are reported with all of these approaches, the lack of consensus on the preferred operation derives from the ability to mount criticism against any or all of them. Free nipple grafting often results in a flat, insensate nipple that is lacking in pigmentation.^14,15 A Wise-pattern inferior pedicle operation is prone to wound-healing problems and hypertrophic scarring at the inverted-T^16-18 as well as a tendency towards bottoming.^19,20 Superomedial techniques, either with a vertical or inverted-T closure, may be novel to surgeons accustomed to inferior techniques, with a longer learning curve^21,22; furthermore, there may be difficulties with folding of the pedicle, especially with more drastic transposition distances.^7,23,24 Designing the reduction based on ultrasound findings will require a certain expertise with ultrasonography. A postero-superopedicle is unfamiliar to most North American surgeons. The short-scar periareolar inferior pedicle reduction mammaplasty can deliver excellent results in the hands of its inventor, but invoking a periareolar closure in extreme macromastia will have a long and steep learning curve for the majority of surgeons. Additionally, even the very definition of “gigantomastia” is unclear with some authors defining it as resection weights >1000 g per breast, whereas others reserve the term for resection weights of >1500 g or even 2000 g per breast; these differences are large enough to render invalid direct comparisons among the various studies.

The majority of patients with extreme macromastia are also obese and although the literature is somewhat divided on whether this increases the risk of breast reduction complications,^25-27 a recent meta-analysis²⁸ suggests that the risk of the major complications of skin and fat necrosis may be twice as high in obese patients. This obesity risk may be additive to the risk of large resection volumes, leading one center to recommend against reduction mammaplasty in morbidly obese patients with estimated resection amounts in excess of 1 kg per side.¹⁸ Some patients would be well served to undergo bariatric surgery before breast reduction,²⁹ but this is only a subset of the presenting population. Nonetheless, despite what may be higher risk, breast reduction still confers substantial benefits on the obese patient.^30,31 The challenge thus becomes the ability to offer reduction mammaplasty with an acceptable complication rate in obese patients with extreme macromastia.

The Robertson Mammaplasty may address some of these concerns. The salient feature of this operation is a bell-shaped curvilinear flap, representing the cutaneous component of the inferior pedicle, inset into the lower pole of the breast. The operation was originally described with free nipple grafting³² but subsequently evolved into a pedicled version.³³ The purported advantages of the Robertson Mammaplasty are safety, simplicity, the familiarity of the inferior pedicle (but without the inverted-T and its potential for wound healing problems), applicability to large resection volumes, as well as good shape and protection from bottoming due to the unviolated lower pole skin envelope.^34,35 The current study was undertaken to retrospectively examine the author’s experience with this operation in the subgroup of heavy or obese patients with extreme macromastia.

METHODS

This study is a retrospective chart/electronic medical record review of the author’s practice over a 15-year period from February 2004 to February 2019. The study followed the guiding principles of the Belmont report insofar as this study falls under the category of practice of “accepted therapy,” which is “designed solely to enhance the well-being of an individual patient and that has a reasonable expectation of success.” Furthermore, all provisions of the Declaration of Helsinki were followed in the conduct of this study, and written informed consent was obtained for all patients. The inclusion criteria were patients who underwent a bilateral Robertson Mammaplasty with a total resection of >3000 g and who were at least 20% above their ideal body weight (body mass index [BMI] of ≥27.3¹). The following demographics were collected: age, weight, height, BMI, sternal notch-to-nipple distance, smoking status, and any comorbid conditions. Resection weights were obtained from pathology reports. The charts and electronic medical records were checked for the complications of nipple necrosis, fat necrosis, infection, wound breakdown, delayed healing, seroma, hematoma, and hypertrophic scarring as well as any other untoward events. “Major” complications were defined as nipple necrosis or any complication that required operation under general anesthesia. Anesthesia records were surveyed to establish “skin to skin” operative times; these records were available for the most recent 20 cases. For the majority of cases, a plastic surgical resident or physician assistant was available to assist with the surgery and to save time with the incisional closure.

Preoperative Markings

Preoperative markings are readily modified from a Wise-pattern so that a surgeon familiar with a Wise-pattern can easily incorporate the Robertson technique. The level of the nipple is marked in the usual manner as the anterior projection of the inframammary fold (Figure 1A). Approximately 5 cm below this point, the lower edge of the upper “apron” flap is determined, with medial and lateral limbs drawn outwards; these limbs are the same as those of a Wise-pattern and meet the inframammary fold at its medial and lateral extents. This is the “upper line” of the markings, and the central configuration of this line is drawn with a mild upwards curve towards the nipple point; this curve follows the bell-shaped curve of the “lower line” as described below. The inferior pedicle is then designed with a width of approximately 15 cm for extremely large cases; the width of the pedicle can be adjusted downwards to approximately 10 cm, depending on the size of the patient and the amount of resection required. The next step incorporates the essence of the Robertson Mammaplasty, which is a bell-shaped extension up from the inframammary fold that is not deepithelialized; the top of this intact skin extension is the “lower line.” The width of this segment is approximately 12 cm wide by 5 cm high; the height in any given case can be determined by considering that the length of the lower pole on closure will be the addition of the height of the bell-shaped curve plus the approximately 3-cm distance from the bottom of the areolar cutout to the upper line (Figure 1B). This lower pole (approximately 8 cm from the bottom of the areola to the inframammary fold) will be longer than the 4.5 to 5 cm that is usually designed in a Wise-pattern mammaplasty. This is not a problem in that the lower pole in a Robertson seems to be more stable, so one does not need to mark the lower pole artificially short in anticipation of bottoming as one should do with a Wise-pattern mammaplasty.^19,20 Furthermore, in these exceptionally large cases the longer lower pole is proportional³⁶ and, as outlined below in the Discussion, may be a factor in reducing the potential for boxiness. These markings are summarized in Figure 1 and demonstrated in the video, available online at www.aestheticsurgeryjournal.com.

Operative Technique

All patients had sequential compression devices applied to the lower legs preoperatively. Subcutaneous heparin was not utilized. No tumescent fluid was employed in this study. After the establishment of general anesthesia, the inferior pedicle is deepithelialized in the usual manner with the obvious exception that the bell-shaped skin extension at the bottom in left intact. The upper “apron” flap is then developed, starting at a thickness of about 1.5 cm. The flap stays this thin up to the level of the areolar cutout in order to facilitate easy inset of the nipple-areolar complex. Continuing upwards past the areolar cutout, the apron flap becomes progressively thicker, reaching a thickness of 4 to 5 cm at the upper chest wall. This flap elevation leads to a widely exposed breast mound that is readily reduced by medial, lateral, and central breast parenchymal resection concomitantly with the development of the inferior pedicle, exactly as would be done with a Wise-pattern inferior pedicle reduction. A single Jackson-Pratt is placed in each side, and the apron flap is advanced over the pedicle with closure of a single long lower incision, followed by inset of the nipple-areolar complex into the areolar cutout. The steps are summarized in Figure 2 and demonstrated in the video.

RESULTS

Thirty-four patients met the inclusion criteria. These patients had a mean age of 44.6 years (range, 23.2-74.1 years), a mean BMI of 36.4 kg/m² (range, 27.3-49.4 kg/m²), and a mean preoperative sternal notch-to-nipple distance of 41.4 cm (range, 35-52 cm). Follow-up ranged from 6 to 49 months (mean, 13 months). Three patients were smokers and 3 patients had type II diabetes mellitus. The mean resection amounts were 1874 g (range, 1460-3010 g) on the left and 1844 g (range, 1514-2807 g) on the right. The mean operative time was 122 minutes (range, 76-148 minutes). There were no instances of partial or complete nipple necrosis. Four patients had areas of firmness in the region of the nipple presumed to be fat necrosis, 1 of whom had bilateral firmness; in 3 patients this firmness resolved over time. Three patients had small (<2 cm²) areas of delayed healing secondary to suture abscesses, 2 of which were at the areola and one of which was along the lower incision. There were 2 cases of cellulitis, 1 unilateral and 1 bilateral, all of which resolved with oral antibiotics. One patient had a seroma that required aspiration. Three patients had hypertrophic scarring; 1 of these requested Kenalog injections. There were no hematomas and no thromboembolic events; 1 patient was admitted overnight for respiratory depression. In summary, there were 18 minor complications from 68 breasts for a minor complication rate of 26.4% and no “major” complications. In terms of revisions, 2 patients had unilateral “dog’s ears” that were excised under local anesthesia and an incision line inclusion cyst was excised from 1 patient under local anesthesia, for a revision rate of 4.4% (3 of 68 breasts). These results are summarized in Table 1.

DISCUSSION

This study defined “gigantomastia” as a condition requiring more than 3000 g of total reduction. The rationale for this strict definition was for clarity of conclusions in that this study considers the largest reductions in the largest patients: with a mean resection weight of 1859.2 g per breast, a mean sternal notch-to-nipple distance of 41.4 cm, and a mean BMI of 36.4 kg/m², it is fair to say that these patients represent the upper end of the breast reduction spectrum. In this high-risk population, the complication rate was gratifyingly low, with no “major” complications and a moderate number of minor complications (26.4%). This is roughly comparable with the minor complication rate of 15.9% that Movassaghi et al³⁵ reported with the Robertson technique. In that series, the patients had an average BMI of 32.4 kg/m² and the average combined resection was 1240 g; thus, the complication rate would be expected to be less than in the current study. These results can also be compared with studies of other mammaplasty techniques with resections of >1500 g per side. Henry et al¹⁸ considered 84 breasts with resection weights of >1500 g per side treated by inferior pedicled Wise-pattern reduction mammaplasty and based on the high complication rate recommended against reduction mammaplasty in morbidly obese patients with an estimated reduction of >1000 g per side. Basaaran⁹ et al employed ultrasound mapping of perforating vessels to “customize” the pedicle for a series of 16 patients with a mean reduction of 1795 g per breast and a mean BMI of 32.6 kg/m². After a radiologist performed the mapping, the pedicles utilized were superomedial, superolateral, and mediolateral. There were no cases of nipple necrosis and 11 of 16 patients had minor complications, including 3 patients with “bottoming out deformity.” Nahabedian⁷ et al reported on their experience with a superomedial pedicle; in 23 patients with a mean BMI of 30.3 kg/m² and a mean resection of 1604 g per breast, there was 1 case that required a free nipple graft because of intraoperative pedicle ischemia. There was no specific mention of other complications. Chang et al,³⁷ utilizing an inferior pedicle Wise-pattern reduction, had 25 patients with a mean resection of >1500 g per breast. These patients had a mean BMI of 37.1 kg/m². The total complication rate was 29.2%, including 1 patient with bilateral nipple-areolar loss. These studies of pedicled techniques with >1500 g resection per side are summarized in Table 2. Finally, we should consider a comparison with free nipple grafting. In a series of 25 patients with an average resection of 1600 g per side, Casas et al⁵ reported one partial nipple graft loss and the absence of bottoming, but no specific mention was made of other complications. Based on these studies, it seems as though when resection volumes exceed 1500 g per side, the Robertson technique as reported herein may be at least on a par with and in some cases superior to other techniques with respect to complications, ease of implementation, and avoidance of nipple grafting.

It is not difficult to postulate some reasons for the low complication rate. The wide and mobile inferior pedicle and the “apron” upper skin flap configuration allow for facile areolar inset: the nipple-areolar complex practically falls into position. There is minimal tension at the lower incision and no tension or tethering at the areolar inset, allowing for a simple layered closure. This contrasts with some techniques for extreme macromastia that invoke specialized sutures to alleviate tension on the closure, such as a “four-point gathering box stitch” ³⁸ or a “tobacco pouch suture,” ¹² or an “interlocking periareolar pursestring suture.” ¹³ Nor is there a need for parenchymal sutures to approximate medial and lateral pillars as in some superior pedicled techniques. These specialized suture techniques will have a learning curve, and because they may involve tension there is the possibility of failure and/or tissue ischemia. With the avoidance of these specialized sutures in the Roberson technique, simplicity becomes a virtue. Furthermore, the familiar inferior pedicle is broad, “shortened”(by virtue of the lack of deepithelialization in the lower aspect) and widely exposed during resection; these factors provide excellent vascularity and would seem to minimize the chances of technical transgressions. The inverted-T with its propensity towards breakdown is completely avoided. Compared with a “no vertical” mammaplasty,³⁹ the bell-shaped lower incision more closely matches the length of the upper incision, which will reduce bunching or pleating and thus unfavorable scarring of the skin closure. So when considering an operation with excellent central vascularity that also avoids watershed zones, tension on the skin and breast tissue, and gathering or bunching of suture lines, a low complication rate does not come as a surprise.

For these very large reductions in these obese patients, the mean operative time was 122 minutes. This is fairly rapid, and the literature has noted a correlation between operative times and complications. For example, Carty⁴⁰ et al examined a series of mostly inferior pedicle Wise-pattern reductions with a mean resection of 841 g per side and found a mean operative time of 134 minutes; furthermore, complications decreased in a linear fashion with decreasing operative time. Likewise, Maintenance of Certification data from the American Board of Plastic Surgery, again with mostly inferior pedicle Wise-pattern reductions with an average resection of 773 g per side and an average operative time of 174 minutes, show that shorter surgical times are associated with fewer adverse events.²⁵ The factors underlying the speed of the Robertson technique have already been alluded to and include the fact that that the deepithelialization zone is somewhat reduced compared with an inverted-T Wise-pattern, the pedicle is widely exposed allowing rapid resection, no specialized sutures are needed, and on-table skin envelope modifications are rarely required. Other authors³³ likewise comment on the speed of the pedicled Robertson mammaplasty, and 1 study³⁵ stated an average time of 1.5 to 2 hours for an average resection weight of 620 g per side. Although the current study does not directly compare operative times of the Robertson mammaplasty with operative times of any other technique, and the diminution of complications with decreasing operative times may have more to do with surgeon experience than with anything else, it does show that these very large reductions can be performed relatively quickly, and this speed/efficiency consideration is consistent with the “risk minimization” mantra that is offered as the principle advantage of this operation.

For any breast reduction method, even one for very large reductions, it is important to consider aesthetic potential. One potential aesthetic issue with the Robertson mammaplasty is the location of the scar; the curvilinear incision in the lower pole of the breast may be seen on the frontal view, which is arguably the most important from the patient’s perspective.³⁹ This potential liability would be worsened if a keloid or hypertrophic scar were to develop. However, in this series the scar was often not seen or barely seen on the frontal view (Figures 3 and 4; Supplemental Figure 1), which agrees with the assertion of Movassaghi et al³⁵ that often the scar is hidden in the shadow of the breast. Other authors contend that patients care more about scar quality than location⁴¹ and that even with this technique the scar location above the inframammary fold is an advantage.³³ Another important aesthetic consideration is the breast shape. In the Robertson technique, the interposition of the lower flap skin into the lower pole skin envelope will reduce the transverse tightening of the skin envelope and reduce the “conization” of the breast that is seen with vertical and inverted-T reduction patterns.⁴² Although a precise plastic surgical term is absent from our lexicon,⁴³ a patient might express the breast shape as being “less lifted” or “less perky.” Furthermore, the absence of any parenchymal sutures (which are avoided for the sake of speed, simplicity, and the minimization of tissue tension) means that the final shape is dependent solely on the skin brassiere. Despite these limitations, in the current study an aesthetically sound shape is often obtained (Figures 3 and 4; Supplemental Figure 1), which is appropriate for the typical body habitus in this population. Other authors have commented on the pleasing shape obtained with the Robertson technique,^33,35 and 94% of patients in an outcome analysis study were satisfied with their postoperative breast shape.³⁴ Another theoretical shape benefit with the pedicle configuration of this operation is the possibility of reduced bottoming. Two studies postulate a reduction in bottoming with the Robertson mammaplasty,^34,35 although the current study does nothing to confirm or refute this possibility.

Although there is a trend in the recent literature towards superior pedicles, even for gigantomastia,^7,8,11,12 it is perhaps prudent to consider some of the benefits of an inferior pedicle. As of 2014, inferior pedicle remained the most commonly utilized technique by members of the American Board of Plastic Surgery.⁴⁴ Although it is not “trendy,” there are some advantages that may underlie its waning yet residual popularity. It is familiar, easy to teach, and may have a lower rate of revision than superomedial vertical techniques.⁴⁵ Some surgeons find that inferior pedicle complication rates do not increase with larger resections,⁴⁶ and this may not be true for superior or superomedial techniques. For example, Kreithen⁴⁷ et al found that a superior pedicle yielded a greater complication rate than an inferior pedicle in cases where the BMI exceeded 30 kg/m², and Neaman⁴⁸ et al found that with a superomedial pedicle, patients with complications had statistically higher resection volumes and nipple-to-fold distances. Furthermore, some authors exclude a superomedial pedicle if its length exceeds 16 cm.²³ So perhaps there is reason to hold on to the inferior pedicle, especially for larger reductions. The Robertson inferior pedicled technique described herein requires only minor modifications from a traditional inferior pedicled Wise-pattern mammaplasty, so that any surgeon familiar with the latter can readily implement the former.

The strengths of this study are that with a single surgeon there is uniformity of assessment, technique, and follow-up. Also, by limiting the study to patients with >3000 g of total resection and a body weight of at least 20% above ideal, there is likewise a certain uniformity of the patient population under consideration. The weaknesses of this study are that it was a retrospective “chart review,” so the data collection might not be as complete or precise as if the data were collected prospectively, the follow-up was limited in that patients typically did not follow-up after their 1-year visit, and there was no control group to which the study patients were compared with except other studies in the literature. A potential weakness of the technique itself is that breast shape is determined solely by the skin brassiere so that long-term shape maintenance is not known.

CONCLUSIONS

Although the Pedicled Robertson Mammaplasty has been advocated as a “versatile” technique, in the author’s opinion its “niche” may be very large reductions in very large patients. As noted previously, these patients are at the highest risk for complications. This operation may be underutilized for this population, and the safety, speed, and simplicity should offset the mildly unusual scar pattern. Overall, the aesthetic results from this technique are quite acceptable, in the author’s opinion, and the fact that the skin envelope and the parenchyma are placed under minimal tension may underlie its low complication rate and high safety profile, which are perhaps the higher priorities in reductions of this magnitude. The goals of functional reduction mammaplasty for gigantomastia should be minimization of complications and good aesthetic potential. For these objectives, the Pedicled Robertson Mammaplasty seems to deliver.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes