Page 295 - Read Online

Zhu et al. Modified Robertson vs. Wise pattern

fullness. More importantly, over time, this technique Outlier patients with extreme body mass index (BMI)
[8]
has been shown to undergo tissue redistribution from (> 40 kg/m or < 26 kg/m ), postoperative breast
2
2
the superior to inferior pole. This phenomenon is volume at early postoperative time point (< 400 mL or
referred to as pseudoptosis and further exacerbates the > 1,300 mL), and the weight of breast tissue resected
lack of superior pole fullness. [2,9-11] (< 400 g or > 1,300 g) were also excluded.
The Robertson technique was first described in Both surgeons marked patients in the standing
1964 [12-14] as an alternative to free nipple grafting in position preoperatively, placing the nipple position at
massive reductions. Later modifications incorporated Pitanguy’s point. In the modified Robertson cohort,
a bell-shaped incision followed by the development the IMF incision was then determined 8 cm below
of a superior apron flap to lower the position of the the new nipple position and marked accordingly.
transverse bell-shaped scar. These modifications Intraoperatively, the new IMF marking was used to
[15]
eliminated the vertical midline scar found in the Wise elevate a superior breast apron down to the chest wall.
pattern, while offering greater flexibility to manipulate The inferior pedicle was created with a base width of
and shape the breast inferior pedicle. Proponents also 12-16 cm, depending on the length of the nipple to
claim that the modified Robertson technique allows for IMF. Once the pedicle was defined, the intervening
greater nipple projection, improved preservation of the tissue was removed, and the apron was draped over
inframammary crease, and less pseudoptosis. [3,16] the pedicle with transposition of the nipple. In the Wise
cohort, the pedicle width was 10-12 cm, and the vertical
While the use of linear measurements can be used as skin incision was made 6-7 cm below the areola.
a proxy for pseudoptosis and changes over time, the
advent of 3D photography and stereophotogrammetry After the surgery, 3D photographs (Canfield Vectra 3D
has allowed for volumetric measurement and objective Camera) were taken during the early postoperative
analysis of breast outcomes. [17-19] The use of 3D period (1-3 months postoperatively) and the late
mammometrics has been validated over the last postoperative period (6-12 months postoperatively).
decade, and has been established in the analysis of Patients who did not return for both photographs were
breast reductions. [20-23] removed from the study. Complications were recorded
during these follow-up visits, including painful scars,
This study uses 3D breast photography and wound dehiscence, infection requiring antibiotics, and
mammometrics to compare postoperative volumetric surgical revision.
and morphologic outcomes between modified Robertson
and Wise pattern inferior pedicle breast reductions. Mammometric and volumetric breast analyses were
completed using Geomagic software. Important
Specifically, we aim to compare postoperative superior landmarks were consistently marked on all images.
pole fullness, pseudoptosis, and breast projection over These included sternal notch, nipple, and point of
time. Other measurements with clinical and aesthetic maximum breast projection. The point of maximum
relevance include sternal notch to nipple distance, projection was defined as the point maximally projected
nipple to inframammary fold (IMF) distance, inter-nipple on the Z-axis on a lateral, profile view of the breast.
distance, areola surface area, total breast volume, The nipple was usually also the point of maximum
and medial pole fullness. This is the first quantitative projection but this did not hold true in all cases. Linear
analysis comparing these two different skin resection measurements recorded include sternal notch to nipple
patterns for the inferior pedicle breast reduction. surface distance, internipple vector distance, nipple
to IMF surface distance, and projection of the breast
METHODS from the chest wall to the nipple and point of maximum
breast projection.
After obtaining Institutional Review Board approval,
patients seeking breast reduction operations between Surface area measurements recorded include the
2012 and 2014 were invited to participate in this study. areola. Volumetric measurements recorded include total
Patients were randomly assigned by the scheduling breast volume, percent volume in superior pole, and
department to either surgeon A, who used a modified percent volume in medial pole. The borders of the breast
Robertson skin incision pattern, or surgeon B, who were defined using the anterior axillary line as the lateral
used a Wise pattern. Exclusion criteria included boundary, the sternal midline as the medial boundary,
age less than 18 years or more than 65 years, the the IMF as the inferior boundary, and the chest wall as
history of breast surgery, the history or presence of the dorsal boundary. Percent superior pole volume was
breast malignancy, and the significant weight change defined as volume of the breast superior to an YZ axial
affecting breast volume during the course of the study. plane through the point of maximum projection divided
Plastic and Aesthetic Research ¦ Volume 3 ¦ September 20, 2016 285