Overly large breasts are a burden. Numerous methods over the years have been designed to reduce their size and weight, but volume reduction alone is not enough. The goal today is to not only reduce size but also create a pleasing shape and, if possible, preserve sensation and function using a skin incision pattern best suited to the individual patient.
As with any procedure that does not have one ideal method, the history of breast reduction is replete with different procedures—all of which have their limitations.1–20 An important advance was made in recent history when Robert Wise21 in 1956 designed a skin resection pattern adapted from a brassiere design, which became known as the inverted T (Fig. 1). Significant advances in pedicle techniques were made by Pitanguy22 in the 1960s, who introduced the superior pedicle; McKissock23 in 1972, with his description of a vertical bipedicle; and Robbins24 in 1977 and Courtiss and Goldwyn25 in 1977 (Fig. 2), who introduced the inferior pedicle. These pedicles were adapted to the Wise skin resection pattern and were taught to plastic surgery residents around the world.
A focus on eliminating the horizontal scar length using the superior pedicle was popularized by Lassus,26,27 Marchac and de Olarte,28 and Lejour et al.29 This approach also enhanced breast shape by reducing the boxy appearance that sometimes occurred with the inverted T. The vertical skin incision pattern has been adapted to inferior,30 medial,31,32 superomedial,33,34 and lateral pedicles.35,36
When suction lipectomy became popular in the 1980s, this method of volume reduction was adapted to the breast to avoid the direct parenchymal resection approaches.37–39 This significantly reduced interference with blood supply and sensory innervation, allowed some elevation of the nipple and tightening of the skin, but is limited to patients with significant fat content of their breasts.
IMPORTANT NEUROVASCULAR ANATOMY
Embryologically, the breast develops as a fourth intercostal space structure, and it has an artery and venae comitantes that come up generally between the fourth and fifth ribs, originating in the internal mammary vascular system.40–43 The superficial blood supply comes mainly from the internal mammary artery as well, with contributions from the superficial branch of the lateral thoracic system and some contribution from the thoracoacromial system (Fig. 3, above). As the breast develops during puberty, the superficial skin and subcutaneous tissue through which the vessels travel gets pushed outward. These vessels course deeply around the periphery of the breast but travel up and around the breast parenchyma toward the nipple.
The blood supply to the various pedicles can be preserved with this understanding of anatomy.44–46 (See Video, Supplemental Digital Content 1, which displays intraoperative markings. The comparison of vertical with inverted T is also discussed and shown in the video. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B388.) The superior pedicle is supplied by the descending artery from the internal mammary system coming usually from the second interspace. It lies in the subcutaneous tissue over the breast parenchyma and can be easily found with a pencil Doppler probe. The medial pedicle is supplied by a branch that curves around the medial aspect of the breast, usually from the third interspace. The lateral pedicle is supplied by the superficial branch of the lateral thoracic artery, which curves up laterally in the subcutaneous tissue around the breast itself. The inferior (and central) pedicles are supplied by the deep system that comes up from the fourth interspace. Arteries from the fifth interspace do come up around the level of the inframammary fold and provide extra blood supply to an inferior pedicle, but these vessels are not available for a central pedicle.
Except for the deep artery with its venae comitantes (which appear to be enclosed between the thin layers of a septum), the arteries course separately from the veins. The venous system can often be seen through the skin, and it drains mainly superomedially.47 The main nerve supply to the nipple and breast skin is the anterolateral branch of the fourth intercostal nerve, which sends a deep branch over the pectoralis fascia and a superficial branch up into the subcutaneous tissue.43,48 (See Video, Supplemental Digital Content 2, which displays the creation of a superomedial pedicle. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B389.) The deep branch curves up toward the nipple at the breast meridian, and this can be preserved with full-thickness medial and inferior pedicles (Fig. 3, below). However, this is not the only innervation. There are also anteromedial branches from the third to fifth intercostal nerves. Supraclavicular branches from the cervical plexus innervate the upper breast tissue.
The surgeon must understand what the patient expects and desires. Managing patient expectations preoperatively is important, and this means that the surgeon must carefully assess each patient’s breast anatomy and communicate what can and cannot be achieved.
Important preoperative anatomical considerations include the degree and location of breast hypertrophy, the amount of skin excess and its elasticity, and the position of the breast “footprint” on the chest wall. Good results are possible with a variety of techniques and approaches, with surgeon experience being an important factor.
The inverted T, inferior pedicle breast reduction is very flexible and adaptable to most breast sizes.49 The inferior pedicle relies on superior parenchymal resection and a strong skin brassiere to hold the remaining breast in position. The inverted-T incision pattern is also well suited to the medial and superomedial pedicles, which are less reliant on the skin as a brassiere.34
The vertical skin resection patterns are mainly applicable to the small and moderate sized breasts with any chosen pedicle.50,51 Much larger breasts or those with very poor quality skin will need a wider skin resection pattern, and skin will need to be removed horizontally and vertically. The surgeon may choose a superior pedicle and plan to use only a vertical skin resection pattern but, if needed, the skin resection pattern can be extended and a horizontal component added. Patients with excellent skin quality will generally achieve a more pleasing cosmetic result with any procedure, and cases with poor quality skin will not be as good.
Some patients are “high-breasted” and some are “low-breasted.”51 The upper breast border can rarely be changed with any of the breast reduction methods, and only minor changes can be made in the breast footprint. All pedicles have some risk of nipple necrosis, even when carefully created. Of the four main arteries available for the nipple, there may be only three dominant vessels, and sometimes the pedicle chosen does not have adequate circulation. Nipple necrosis may be more often a problem with a nondominant blood supply rather than intraoperative error.
In the very large breast, the surgeon may believe that the circulation to any pedicle is not going to be reliable, and may choose to use a free nipple graft.52 This decision will result in a flatter nipple that lacks both sensation and the ability to breastfeed.
Following individualized patient assessment, the specific technique is selected and the procedure with location of incisions is outlined for the patient on a diagram or even on her own skin. We explain it as a “tradeoff” of scars on the breast for functional and/or cosmetic improvement. Patients are informed that the resulting scars will be permanent and that scar healing is unpredictable.
The patients are first educated regarding the surgical risks (those things related to wound healing) and then about cosmetic risks (those things related to appearance) (Reference 57, Level of Evidence: Risk, III).53–59 It is important to inform patients about the possible loss of sensation to the nipple-areola complex or even the skin of the breast,60–70 inability to lactate,71 and the rare possibility of nipple-areola loss and the likelihood of breast asymmetry72 following surgery (Reference 70, Level of Evidence: Therapeutic, III).
Preoperative mammography is the most sensitive screening tool for analyzing the breast gland for abnormal pathologic conditions.73 Mammography is ordered based on the recommendations of the governing organizations in a given country. In the United States, women have their first mammogram at age 40, whereas in Canada and Europe, the screening begins at age 50. In patients with a strong family history or other risk factors for breast cancer, a mammogram may be obtained at age 35.
DESIGN AND PREOPERATIVE MARKING
The key to a good breast reduction design is having an understanding of what the chosen method can offer in relation to the breast footprint and the breast shape in both the short term and the long term. (See Video, Supplemental Digital Content 3, which displays blood supply to the nipple and other various pedicles. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B390.) Once the surgeon can visualize the result that the mound shaping will achieve, a decision can be made about nipple positioning. The optimal method of identifying the exact location of the inframammary fold is by placing a tape measure horizontally in the fold under both breasts. Although many surgeons advise placing the new nipple at the level of the inframammary fold, this is sometimes misleading. The ideal nipple position is slightly below the middle position on the breast mound. The nipple appears better in the lower half of the breast than in the upper half. It is always easier to raise a nipple that has been placed too low, but it is difficult to lower a nipple that has been placed too high.
It is better to be able to visualize the final result and then determine the new nipple position. In general, an ideal nipple on an average C cup brassiere is approximately 10 cm down from the upper breast border and approximately 10 cm from the chest midline (drawn straight, not around the breast). Some surgeons prefer to place the nipple at the level of the inframammary fold, but all surgeons need to be able to stand back, evaluate their design, and make adjustments as needed.74
The breast meridian should not necessarily be drawn through the preoperative nipple position, but it should be drawn through the ideal nipple position. A nipple appears best when it points slightly outward and slightly downward—it is better to place it slightly too low and slightly lateral if in doubt. The surgeon who performs both a standard inverted-T inferior pedicle breast reduction and a vertical breast reduction will realize that the inverted-T breast will have a wider horizontal base, and the new nipple position should be farther lateral than a vertical breast reduction (which results in a narrower breast base).
The inverted-T, inferior pedicle design uses the Wise pattern for the skin that remains as a brassiere to hold the breast shape (Fig. 2). Many of the vertical procedures use the Wise pattern as a pattern for the parenchyma that remains, and the skin then redrapes over that pattern (Fig. 1). The inverted-T design tries to match the horizontal length of the skin flaps to match the total horizontal length of the inferior incision (in or just above the infra mammary fold). Some surgeons design the areolar opening preoperatively, and some design it intraoperatively. The circumference of the areolar skin opening should match the circumference of the ideal areola. Areolar skin is more elastic and tends to stretch out to fit the areolar opening. When a surgeon uses a “circumvertical” pattern, a permanent suture is often needed to prevent stretching.30,75 The circumference of a 5-cm-diameter areola is 16 cm, and the circumference of a 4.5-cm-diameter areola is 14 cm (the original Wise pattern).
The angle of divergence for the vertical limbs of the skin resection pattern will depend on the size of the breast. The important determinant is what is left behind (which should be symmetrical from side to side) and not what is being removed. We believe that it is very helpful for the surgeon to pinch the vertical limbs together and make sure that closure without tension can be achieved. When the skin is being used as a brassiere, the skin flaps need to be fairly tight, but in a vertical approach, the skin resection pattern is not being used to hold the breast but can be loose because it only needs to adapt to the new breast shape. There is an ongoing controversy about the ability of the skin to act as a brassiere in determining long-term breast shape.
The chosen pedicle is usually deepithelialized first (Figs. 4 and 5). (See Video, Supplemental Digital Content 4, which displays innervation to the nipple and other various pedicles. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B391.) It is important with an inferior pedicle that it be created full thickness because the blood supply is deep from the fourth interspace. Some surgeons will suture the pedicle up to the chest wall, but there is no evidence that these sutures hold in the long term. They may, however, help to hold tissue in place so that breast tissue has a chance to heal to other breast tissue, providing a permanent shape. The skin and parenchyma are resected next. Some surgeons prefer cutting cautery to remove parenchyma, and some use a cold scalpel. There is no evidence that one is better than the other.
Medial, superomedial, superior, and lateral pedicles can be thinned. The arteries enter the breast deep at the breast periphery but they then travel in the subcutaneous tissue and enter the areola superficially. The medial and lateral pedicles are usually kept full thickness to try to preserve ducts and sensation, but often the superior pedicle needs to be thinned so that it can be more easily inset. The lateral and medial pedicles are rotated into position and the whole base rotates as well. The superior pedicle76 needs to be folded up; if it is not thinned, the arteries can end up being inadvertently compressed.
With the inverted-T inferior pedicle procedure, both skin and breast tissue are removed from above the pedicle centrally but below the Wise pattern medially and laterally. This creates a horizontal type wedge resection of skin and parenchyma, and this tends to create a medial and lateral dog-ear. It is important to try to match the length of the skin flaps to the incision in the inframammary fold to help try to prevent these puckers. It is important to remove tissue deep to the skin to smooth out the dog-ear effect.
With the vertical type approaches that use a medial, superior, or lateral pedicle, both the skin and parenchyma are removed as a vertical wedge.77–80 (See Video, Supplemental Digital Content 5, which displays parenchymal resection. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B392.) This means there are also two dog-ears created but superiorly and inferiorly rather than laterally and medially. The superior dog-ear is absorbed into the new areolar opening, but the inferior pucker can create problems. Small puckers will settle, but larger puckers can be removed by adding further skin resection horizontally. The puckers with the vertical approaches may need later revision. (See Video, Supplemental Digital Content 6, which displays final resection and closure. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B393.) It is harder to correct the medial and lateral dog-ears from the inverted-T approaches. The vertical incision should not be gathered because the extra length is needed to accommodate projection. Cinching the skin also leads to wound healing problems and is unnecessary because the incision stretches out with time. In contrast, if it does not stretch, the surgeon may need to revise the pleating that is left behind81 (Figs. 6 and 7). Liposuction can be performed beyond the Wise pattern in any type of breast reduction to help shape the peripheral fatty tissue. This is the primary role of suction lipectomy in breast reduction. (See Video, Supplemental Digital Content 7, which displays how suction lipectomy is incorporated into the procedure and discusses the pucker that results at the bottom end of the vertical incision. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B394.)
Skin closure is best achieved without tension to prevent delayed wound healing problems. Because the inverted-T inferior pedicle design relies on the skin as a brassiere, skin repair under some tension is essential. It is essential to elevate and handle these skin flaps in such a way as to include all adipose tissue above the superficial fascial system to minimize problems with the flaps. Tension is not needed in the vertical approaches and should be avoided if at all possible, because tension can actually be detrimental to initial shape resolution. (See Video, Supplemental Digital Content 8, which displays the summary of superomedial vertical breast reduction with inclusion of preoperative and postoperative photographs of the patient. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B395.) In the unusual event that a suspicious mass is encountered during a breast reduction, the next steps will depend on the nature of the mass and the stage at which the mass is found.82,83 If frozen section is available, this will help to define the problem. If such is not available, the mass can be resected and the surgical site marked with surgical clips. The breast procedure can be terminated with closure or completed, depending on the stage of the procedure.
There is no consensus on drain use, but the principle is to remove fluid and blood that build up in the potential dead space from tissue removal. Generally, drains are removed when the output is less than 25 to 30 cc in a 24- to 48-hour period.
Bacteria are present in breast ducts, and most surgeons accept that breast surgery is not completely “clean.” At least one preoperative antibiotic dose is usually used, and some surgeons will continue antibiotics, especially for large breast reductions or in patients with higher body mass indexes.84
Many surgeons will use glue or tape to cover the incisions. Patients are allowed to shower once the incisions are sealed (usually 24 hours) or once the drains are removed.
Most surgeons will use a surgical brassiere or wrap for a couple of weeks postoperatively to provide some form of support. Excess compression is not advisable, to avoid compressing the circulation to the nipple-areola complex.
Early Wound Complications and Delayed Wound Healing
Wound healing problems, open wounds, and skin loss are the most commonly encountered complications in the breast reduction surgery patient. The incidence of these complications increases with the resection weight of the specimen. They are normally at the point of greatest stress or “tension” on the closure and in the areas that are most remote from the blood supply. These may progress to partial wound dehiscence. The deleterious effects of cigarette smoking following breast reduction has been studied and confirmed in the literature in both prospective85 and retrospective studies.86
Hematoma and Seroma
The rate of major hematoma formation in breast reduction is approximately 1 to 2 percent. Seromas usually appear later and may be aspirated. Seromas are less likely to resolve spontaneously with the inverted-T skin resection pattern than with the vertical pattern because the inframammary scar can block drainage. (See Video, Supplemental Digital Content 9, which displays inverted-T inferior pedicle markings and surgery. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B396.)
Partial or total nipple necrosis, although a well-described complication of breast reduction, can be devastating for the patient and the surgeon. It is not always possible for a surgeon to make the diagnosis of nipple ischemia, especially in black or dark skin patients. In light skin patients, circulatory problems are suggested by a nipple that is pale or dusky. The former is suggestive of arterial insufficiency, but purple congestion is associated with poor venous outflow.
In large reductions, the pedicle may be folded and compressed, resulting in a decrease in circulation. If tension is suspected, surgical maneuvers to alter this tension can be initiated. Sometimes, simply removing sutures will restore circulation. It may be best, if initial maneuvers are unhelpful, to allow the nipple to declare itself over time and allow any devitalized areas to demarcate before any definitive treatment is attempted. It is surprising that nipples that appeared quite threatened at the time of surgery can in fact show viability, especially if the surrounding areola tissue is viable.
The most common long-term complications of breast reduction include suboptimal scar formation, such as hypertrophic, painful, or even keloid scars, and problems with loss of shape with loss of upper pole breast fullness (bottoming-out), nipple malposition, and asymmetry. A common problem shared by virtually all techniques of breast reduction is inferior descent of the lower pole of the parenchymal tissue. When breast tissue is left in the most dependent region of the breast, predisposing it to be acted on by gravity, bottoming-out can occur, and this type of breast reduction can actually push the inframammary fold to a lower level. Bottoming-out can be caused by recurrent glandular ptosis in all reduction techniques if the surgeon attempts to push tissue up higher into the upper pole. It will inevitably drop back down, especially if not enough of the inferior gland is removed.
All humans are asymmetric. Liposuction is a valuable treatment adjunct in reducing the volume of a previously operated breast, and in such a situation, tightening of the skin envelope to enhance the symmetry and breast shape can be achieved by “tailor-tacking” to optimize skin envelope symmetry, deepithelialization, and skin edge reapproximation.
Large suture bites used in the breast parenchyma are not only unnecessary but can also cause fat necrosis. Breast tissue should only be approximated—not sutured under tension. Fat necrosis can also result at the distal end of a pedicle from lack of blood supply.
Breast reduction can be accomplished by several different methods. All involve a pedicle design (or free nipple graft) to move the nipple-areola complex, a parenchymal resection pattern, and a skin resection pattern. Most surgeons should have several different options in their repertoire to adapt to different patient presentations.
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