Superomedial Pedicle Breast Reduction in Patients with Sternal Notch-to-Nipple Distances Greater than 40 cm

BACKGROUND: The superomedial pedicle (SMP) is favored for preserving nipple-areolar complex (NAC) vascularity and superior pole fullness. However, its use in breast reductions (BR) with sternal notch-to-nipple (SN-N) distances ≥40 cm is debated. This study evaluates the safety and efficacy of SMP in such cases. METHODS: A retrospective review was performed on patients who underwent SMP-based BRs from March 2022 to February 2025. Inclusion criteria included age ≥18, SN-N ≥40 cm, and ≥1 month follow-up. RESULTS: 54 breasts (29 patients) were included. Median resection weight was 1,237.5 g per breast (range: 750-2,600 g). Median SN-N distance was 42.0 cm (range: 40.0-48.0 cm). Five (9.3%) breasts experienced at least one complication: hematoma (n=1), minor dehiscence (n=1), fat necrosis (n=1), and minor skin necrosis (<2 cm; n=3). No reoperations occurred. Breasts were stratified by a 1,240 g resection cutoff. Patients in the >1,240 g group had higher BMI (40.7±5.4 vs. 37.6±5.3; p=0.041). On multivariable logistic regression, adjusted for BMI, N-IMF, SN-N, and resection weight, there were no statistically significant associations with complications (all p≥0.05). Propensity score matching revealed, which included BMI, N-IMF, and SN-N, complication rates were comparable between >1,240 g (n=27 breasts) and ≤1,240 g (n=12 breasts) groups (average treatment effect on the treated=0.111; p=0.829). CONCLUSION: SMP is safe in patients with SN-N ≥40 cm and large resection weights. These findings challenge the notion that SMP is contraindicated for SN-N >35 cm and suggest that, with technique modifications, it can be safely used in longer SN-N distances without increased complications.