“Bifidus Pedicle”, the Use of Bilobed Superomedial Pedicle for Breast Reshaping Following Upper Outer Quadrantectomy: A New Oncoplastic Breast Surgery Technique

We read with great interest the article titled: ““Bifidus pedicle”, the use of bilobed superomedial pedicle for breast reshaping following upper outer quadrantectomy: a new oncoplastic breast surgery technique” by Marongiu F et al., in which the authors described a very interesting technique for breast reconstruction after upper outer quadrantectomy with the use of a modified superomedial pedicle combined with a Wise skin resection pattern [1]. We congratulate the authors for a new interesting reconstructive approach, based on both volume displacement and volume replacement to obtain an aesthetically pleasant mammary cone in a single surgical step, but we have some elements to discuss. The suspension apparatus, described by Würinger [2], not only provides a ligamentous suspension of the breast, but also includes nerves and vessels that contribute to the nipple–areola complex’s vitality [3], but it does not support the inferolateral part of the parenchyma where the described adjunctive second flap is harvested [4]. Even if the use of Würinger septum represents a valid adjunctive blood supply to the flap, preserving the medial portion of the septum may represent a limit to an easy mobilization of the bifidus flap in achieving the most distal part of the upper outer quadrant that must be reconstructed during oncoplastic breast surgery. The blood supply of the breast parenchyma comes from many sources, including intercostal perforator arteries emerging from the third to the sixth intercostal spaces that efficiently supply the lateral part of the breast tissue, including the adjunctive second flap described by the authors to the conventional superomedial pedicle described by Hall-Findlay. We congratulate the authors for the interesting case series showing very pleasant cosmetic breast reconstruction, but, in the presence of extremely lateral resection during oncoplastic breast surgery, the resection of both lateral and medial aspect of the Würinger septum could be required to allow an efficient mobilization of the flaps to achieve a more conical and aesthetically pleasant breast reconstruction [5]. Preserving the intercostal perforator arteries should be considered to guarantee an adequate vascularization of the flaps, when resection of both suspension ligaments is required, as a perforator-like support to the bifidus flap.