Yazan Masannat, Consultant Oncoplastic Breast Surgeon, Aberdeen Royal Infirmary

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Wise Pattern Therapeutic Mammoplasty is a technique often used for breast conservation. The suitable candidate is a lady with a relatively large cup breast and an element of ptosis. The planning and marking for this is similar to the cosmetic breast reduction but the difference is in the breast resection as oncology is the priority.

 

Marking is very similar for all wise pattern mammoplasties and breast reductions with some variation between different surgeons. You can see from the marking video below that it is very similar to the marking for the breast reduction marking by Mr N Niranjan thought the pedicle used for nipple preservation is different.

 

In the therapeutic setting there are oncological considerations that might dictate the pedicle used to preserve the nipple and in some cases the nipple is sacrificed. Another important point to consider is that the ladies for therapeutic mammoplasties are usually older than the ladies that have cosmetic breast reductions and the final shape of the breast and the nipple position is usually slightly lower to give them a breast that is suitable for their age.

 

Marking

 

The patient is marked standing up. The midline is marked first from the suprasternal notch down to the umbilicus. The breast meridian is marked after using a measuring tape put around the patients neck and going down the breast usually throught the nipple. In certain patients if the nipple is lying too medially to too laterally then the meridian is moved so than the level of the meridian and the nipple will be roughly at the level of the midclavicular line.

 

The level of the nipple or the highest point of the wise pattern marking varies depending on the patients height, shape of the breast and the footprint of the breast, usually is at the level of the inframammary fold. After marking the highest point of the marking the two vertical lines of the wise pattern is drawn down while pushing the breast to each side. The length of these lines will vary depending on the body frame of the patient and if the highest point of marking is the level of the nipple or the highest point of the areola, it is usually 7-9 cm. I tend to use 9cm lines, and then measure the distance between the distal part of the vertical limbs and it shouldn't be more than 12cm otherwise the closure might be tight.

the lateral and medial lines are marked as shown in the videos below. The inferior line is drawn in the IMF and I would leave a triangle at the meridian just in case the closure is tight then using that will decrease the tension and the chance of tissue loss at the T-junction and it is easy to excise if it is not needed.

 

Surgery

 

The first thing to do is to remark everything on the table, and then measure the length of lateral and medial lines and make sure that they are the same length or longer than the line inferior line in the IMF to decrease tension on the closure. The pedicle is de-epithelialised using curved scissors of a knife and the the resection and reduction is done as shown in the video trying to mirror the resection in both sides to achieve better symmetry.

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