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Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes

Colohan, Shannon M. M.D., M.Sc.; Massenburg, Benjamin B. M.D.; Gougoutas, Alexander J. M.D.

Author Information
Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 339e-350e
doi: 10.1097/PRS.0000000000007263

Abstract

Breast reduction is a common procedure performed by plastic surgeons, with an increasing proportion of private-pay (cosmetic) reductions being performed annually. The number of cosmetic reductions published by the American Society of Plastic Surgeons in 2017 was 43,635 (up 11 percent since 2016), and the number of reconstructive (insurance-paid) reductions was 59,463 (down 4 percent since 2016).1 There is no doubt that patient satisfaction with this procedure is high,2 and postoperatively women have been found to have improved anxiety, depression, and body image satisfaction.3

The generation of outcomes-based data allows us as surgeons to assess our techniques with respect to surgical results, complications, and patient satisfaction. More recently, there has been an increasing focus on patient-reported outcome measures, especially as emphasis has shifted toward patient-centered care. Collecting information on patient-reported outcome measures allows us to evaluate the effect our care may have on a patient’s health status. Data collection is primarily achieved by means of validated questionnaires that seek a patient’s evaluation of their symptoms and quality of life. This provides valuable information on a patient’s outcomes, and whether or not the reason they sought care/surgical intervention was ameliorated or cured postoperatively. Patient-reported outcome measures capture patient-centric information, beyond the usual metrics of surgical complications, readmission, and medication use.

BREAST REDUCTION SURGICAL TECHNIQUES AND OUTCOMES

History

One of the first published descriptions of breast reduction was in a French article by Raymond Passot in 1925.4 His proposed incisions were marked out with silver nitrate pens, including periareolar and inframammary. He described treating gland and skin as separate—a concept that still holds true of today’s modern techniques. He also addressed the need to correct shape through resection of the ptotic inferior pole along with medial/lateral breast tissue; however, these descriptions did not address (and possibly threatened) the blood supply to the nipple, and more contemporary surgeons are more leery of this method.5

Anatomy

Understanding the blood supply to the breast is important to maintain adequate supply to the nipple-areola complex, and the breast parenchyma to avoid nipple ischemia and fat necrosis. The primary blood supply is from the internal mammary system, with additional contributions from the lateral thoracic and thoracoacromial systems. It is based on this knowledge that several pedicles have been designed/described for breast reduction. The venous system is more superficial in the breast, and drains primarily superomedially.6

The innervation of the breast and nipple is derived from the intercostal nerves, with contributions from both anterior (medial) and the second through sixth lateral intercostal nerves, and a primary contribution from the fourth intercostal segment7 (Fig. 1).

Fig. 1.
Fig. 1.:
Anatomy of the breast. Dominant blood supply (red) and innervation (blue).

Inverted-T Techniques

The Wise pattern with inferior pedicle technique remains the most common in use among American board-certified plastic surgeons.8 First described by Robert Wise in 1956, this technique uses a flexible latex pattern to plan skin flaps, and a second device (mold) to determine the size and shape of the gland. This was based on his evaluation of standard brassiere sizing and his desire to overcome shortcomings of shaping of previously described techniques.9

The pedicle used with an inverted-T technique may be varied, and can include inferior, superior, superomedial, medial, lateral, central, and bipedicle techniques (Fig. 2). Choosing a pedicle may depend on patient characteristics (degree of nipple ptosis relative to proposed nipple placement, size of breast and anticipated reduction volume, and prior surgical scars). It may also be based on the surgeon’s experience and comfort, and perceived benefits or pitfalls of the various pedicle choices. For example, inferior pedicle techniques are considered reliable, with good “on-the-table” appearance, but have been criticized for their boxy appearance or tendency to bottom-out over time (Fig. 3). Superior/superomedial pedicles have excellent pedicle vascularity and postoperative shape with less bottoming-out, but can require rotation of the nipple-areola complex, which may make inset challenging (Fig. 4).

Fig. 2.
Fig. 2.:
Breast reduction techniques. Inverted T, inferior pedicle (above, left), inverted T, superomedial pedicle (above, center), vertical, superomedial (above, right), vertical, superior (below, left), perioareolar/central (below, center), and free nipple graft (below, right).
Fig. 3.
Fig. 3.:
Wise-pattern breast reduction using an inferior pedicle. Preoperative views (above) and postoperative views (below) are shown. Resection weights were 520 g on the right and 400 g on the left.
Fig. 4.
Fig. 4.:
Wise pattern breast reduction using the superomedial pedicle. Preoperative views (above), intraoperative views demonstrating the superomedial pedicle and glandular resection (center), and postoperative views (below) are shown. Note the thinning of the superomedial pedicle, and the wide zone of resection inferiorly and retroareolar to produce a large volume reduction.

The basic skin pattern involves marking the breast meridian (which may or may not line up with the nipple) and the inframammary fold. The position of the new nipple areola-complex is identified by palpating the position of the inframammary fold as it translates anteriorly through the breast parenchyma. Alternatively, one can mark the new nipple-areola complex at 10 cm below the upper breast border, as this may be less subjective. Care should be taken not to mark the nipple-areola complex too high, especially in a heavy/pendulous breast, as this could result in a nipple-areola complex that is too high or not centered on the breast mound. Vertical limbs are marked extending inferiorly from the nipple-areola complex approximately 8 to 9 cm from the proposed nipple position. The width of these limbs is estimated by cupping the breast with one hand and rotating medially and laterally to assess where the breast meridian (translated onto the upper abdomen) lies with each movement. The width typically increases with wider based breasts or larger reductions. A line joining these vertical limbs with the inframammary fold is drawn both medially and laterally; the lateral component may incorporate an S-shaped curve to help reduce boxiness. [See Video 1 (online), which displays markings for Wise-pattern breast reduction.]

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The chosen pedicle is then marked with a base that incorporates the dominant blood supply of that pedicle. The nipple-areola complex is then marked with a sizer (38 to 45 mm, depending on preference) and the pedicle around the nipple-areola complex is deepithelialized. Glandular tissue is then resected, with care to preserve adequate thickness of the skin flaps (1.5 to 2 cm) and pedicle. Inset is then performed as a layered closure after meticulous hemostasis. Superior/superomedial pedicle techniques require some nipple-areola complex rotation or folding of the dermal pedicle to bring it into appropriate position. The new nipple-areola complex position is defined either by keyhole incision markings placed preoperatively, or by using a nipple sizer to mark its position intraoperatively after reduction. [See Video 2 (online), which displays the superomedial pedicle for Wise-pattern breast reduction.]

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Many studies have aimed to compare short-scar techniques with inverted-T excision techniques to determine long-term outcomes with regard to shape. These have highlighted the tendency for inverted-T reductions to have a greater degree of nipple-areola complex inframammary fold elongation. Studies that have looked at both inferior and superior or superomedial pedicles using an inverted-T skin excision pattern have evaluated this as well. One study looked at mean preoperative length, intraoperative length, and postoperative length of the nipple-areola complex inframammary fold, noting an average 80.5 percent elongation for the superior pedicle versus 92.9 percent for the inferior pedicle (p = 0.077) techniques.10 Another study looked at the superomedial versus inferior pedicle in gigantomastia patients undergoing inverted-T reduction. They did not note any differences in postoperative complications, nor did they observe a significant difference in nipple-areola complex inframammary fold length between the two techniques.11

Short-Scar Techniques

Short-scar techniques evolved as a way of addressing the scar burden and shape of the reduced breast. Descriptions of purely periareolar reductions exist but are plagued with problems including postoperative areolar widening and ptosis. The most widely popularized technique is likely that of Benelli, which is based on a central pedicle/mound, in which a donut skin excision is performed along with a small reduction with a pursestring closure.12 The use of interlocking Gore-Tex (W. L. Gore and Associates, Flagstaff, Ariz.) suture as described by Hammond et al. offers a possible solution for areolar widening13 (Fig. 5).

Fig. 5.
Fig. 5.:
Interlocking Gore-Tex periareolar suture technique for periareolar closure to avoid postoperative widening of the nipple-areola complex. This patient had a tuberous breast deformity and wanted correction of the nipple-areola complex herniation without correction of the volume asymmetry.

The majority of short-scar techniques rely on a superior or superomedial pedicle for nipple vascularity. Although first described by Arie,14 the popular descriptions of this technique arose primarily from the work of Lassus and Lejour. Lassus first lectured on his short-scar technique as early as 1969, and published his 30-year experience in 1996.15 His technique was based on a superior pedicle, central wedge resection, no undermining, and a vertical-only scar. Extending on this work, Lejour started her experimentation with vertical mammaplasties in 1989, and incorporated a mosque pattern skin marking, more extensive glandular excision, and glandular/pectoralis fascia sutures.16 Today, the most commonly used vertical technique is that popularized by Hall-Findlay, in which she modified the Lejour technique by converting to a medial (or more recently, superomedial) pedicle, minimal skin undermining, no pectoralis fascia sutures, and minimal or no liposuction.17 The transition of Hall-Findlay to using a superomedial pedicle allows a more robust blood supply from the second and third interspaces. This may make nipple-areola complex inset a bit more challenging, but given the excellent superficial blood supply to the nipple-areola complex, it is possible to remove some of the deep tissue to allow better rotation.18

For the surgeon embarking on a vertical technique, there is definitely a learning curve.19 This includes placing the nipple-areola complex slightly lower than one would think, as it has a tendency to rise up with vertical reduction. Although the vertical scar can be quite long (in some cases, up to 8 cm), it is important to ensure that the skin incision ends 2 to 4 cm above the inframammary fold. It is also very important to remove or thin out the breast at its base/above the inframammary fold to improve the transition of the scar from breast to chest wall and raise the inframammary fold. This is what allows a longer vertical scar to be accommodated in this technique. The on-table appearance of these breasts can also be disconcerting, as the breast will appear quite empty inferiorly (“upside-down” appearance), and the shape will not be ideal at this stage and will settle in over months postoperatively (Fig. 6).

Fig. 6.
Fig. 6.:
Hall-Findlay superomedial breast reduction in a teenage patient (above). Intraoperative photographs demonstrate the upside-down on-table appearance (center). Postoperative follow-up at 1 year shown (below).

A number of studies examining outcomes of vertical reduction mammaplasty have been completed, with many of these comparing vertical techniques to the more “traditional” inverted T. These studies highlight the need to evaluate not only scar burden, but also longevity of shape, in addition to postoperative complications such as delayed wound healing and nipple sensory loss.20 Another consideration is that as the rate of complications in breast reduction is relatively low, such studies are often underpowered to determine any differences, and may not have follow-up that is long enough to ensure all postoperative complications are captured appropriately.21 In a prospective study where women were randomized to inverted-T versus vertical scar reductions preoperatively, both groups demonstrated clinically important improvements in health-related quality of life, with no difference in outcomes between techniques.22 Photographic evaluation of postoperative outcomes has demonstrated that vertical reductions may have an advantage with regard to increased upper pole projection and less constriction (i.e., boxiness) of the lower pole.23

No Vertical Scar Reduction

This was originally described by Passot,4 but has been popularized by Lalonde et al.24 It involves an inframammary and periareolar incision, with breast-shaping sutures placed before final closure. This technique may be very useful in the gigantomastia patient with significant ptosis. Its criticisms include a wide, flat, boxy shape that has a greater lower pole width–to–lower pole length ratio25 (Fig. 7). Although none are published, it would be interesting to look at patient-reported outcomes as to whether the elimination of the vertical scar and its tradeoff for a potentially boxier shape is preferred by the patient.

Fig. 7.
Fig. 7.:
No-vertical scar technique. Preoperative (above) and postoperative (below) views demonstrating minimal scar burden and acceptable shape.

Reduction with Free Nipple Grafting

Free nipple graft techniques may be indicated in cases with significant ptosis (notch-to-nipple distance >40 cm), gigantomastia (>1800-g anticipated reduction), comorbidities that preclude longer times under anesthesia, and prior breast surgical scars that interfere with the desired/planned pedicle. Of course, it may also be indicated for nipple salvage should it appear compromised intraoperatively during standard reduction. These techniques may involve preservation of a superior/superomedial/inferior dermal glandular pedicle, typically combined with inverted-T skin excision. Criticisms include lack of projection, boxy/flat shape, partial loss of nipple graft resulting in asymmetry, and depigmentation. Many articles have been published describing ways to help improve the shape and cosmetic outcome of this operation.26,27 There are no published outcomes studies on this method, presumably because of low frequency of use.

PERIOPERATIVE AND POSTOPERATIVE CARE

An evidence-based review of breast reduction with particular emphasis on this topic was published by Greco and Noone.28 A summary of the recommendations that incorporate evidence-based medicine can be found in Table 1.

Table 1. - Evidence-Based Recommendations in Breast Reduction
Screening mammography
 American Cancer Society guidelines (2015)*
  Annual screening for women aged 45–54 yr; biennial screening after age 55 yr
  Women aged 40–44 yr have the opportunity to begin annual screening
  Clinical breast examinations not indicated for cancer detection/surveillance
Antibiotic use
 Joint committee of the ASHP, IDSA, SIS, SHEA (2013)
  Cefazolin or ampicillin-sulbactam within 60 min before surgical incision
  Add vancomycin if known to be colonized with MRSA
  Clindamycin or vancomycin if beta-lactam allergic, 120 min before surgical incision
Deep venous thrombosis prophylaxis
 No formal evidence-based recommendations on giving chemoprophylaxis [e.g., heparin or Lovenox (Sanofi-Aventis, Bridgewater, N.J.)]; suggest giving for patients with “higher” VTE risk (Caprini score >5) or patients undergoing combined procedures
 Risk factors in breast reduction: older patients, patients requiring blood transfusion, patients with unplanned return to operating room
 Reasonable to consider stopping oral contraceptives/hormone replacement 1 mo before/2 wk after surgery, encouraging early postoperative mobilization,§ use of intermittent pneumatic compression devices placed 30 min before anesthesia induction
Use of postoperative drains
 Multiple studies showing no benefit in drain use, except possibly with concomitant liposuction
ASHP, American Society of Health-System Pharmacists; IDSA, Infectious Diseases Society of America; SIS, Surgical Infection Society; SHEA, Society for Healthcare Epidemiology of America; MRSA, methicillin-resistant Staphylococcus aureus; VTE, venous thromboembolism.
Bratzler DW, Dellinger EP, Olsen KM, et al.; American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283. 10.2146/ajhp120568
Rubio GA, Zoghbi Y, Karcutskie CA, Thaller SR. Incidence and risk factors for venous thromboembolism in bilateral breast reduction surgery: An analysis of the National Surgical Quality Improvement Program. J Plast Reconstr Aesthet Surg. 2017;70:1514–1519. 10.1016/j.bjps.2017.05.050
§Iorio ML, Venturi ML, Davison SP. Practical guidelines for venous thromboembolism chemoprophylaxis in elective plastic surgery. Plast Reconstr Surg. 2015;135:413–423. 10.1097/PRS.0000000000000908
American Society of Plastic Surgeons. Evidence-based clinical practice guideline: Reduction mammaplasty. Available at: https://www.plasticsurgery.org/Documents/Health-Policy/Guidelines/guideline-2011-reduction-mammaplasty.pdf. Accessed January 6, 2019.

Preoperative Mammography

The guidelines published by the American Cancer Society in 2015 recommend that women who are at average risk of developing breast cancer should begin yearly mammograms at age 45.29 Women have the option of starting screening at age 40. Clinical breast examinations (provider examination or self-examination) are no longer recommended. Women with higher risk of developing breast cancer should start screening earlier, as directed by their medical provider. As part of their Choosing Wisely campaign, the American Society of Plastic Surgeons American Board of Internal Medicine Foundation has recommended that patients avoid routine mammograms before elective breast surgery unless conforming to existing screening guidelines or responding to a concerning physical finding.30 A more recent study looking at 52,486 women being evaluated for macromastia demonstrated a significantly higher rate of screening mammography among women in their twenties and thirties compared to the rate among women in a general population cohort (twenties, 4.3 percent versus 0.2 percent; thirties, 30.1 percent versus 5.7 percent, for macromastia patients versus the general population).31 This led to 14 percent of macromastia patients younger than 40 undergoing subsequent tests or procedures, with an overall rate of 0.5 percent breast cancer diagnosed among these. This further supports the American Society of Plastic Surgeons initiative to limit mammography to the published guidelines stated above.

Antibiotic Use

Clinical practice guidelines for antimicrobial prophylaxis in surgery were developed and published in 2013. For elective plastic surgery procedures including breast reduction, the recommendations are for cefazolin or ampicillin-sulbactam within 60 minutes before surgical incision.32 Vancomycin may be added for those patients known to be colonized with methicillin-resistant Staphylococcus aureus. Patients who are beta-lactam allergic should receive vancomycin or clindamycin at least 120 minutes before incision. In addition, for any procedures where pathogens other than staphylococci and streptococci are likely, the surgeon may consider adding another agent with activity against these other anticipated pathogens.

Anticoagulation

Although there are no formal evidence-based recommendations on giving chemoprophylaxis in breast reduction, it is suggested that it be given to patients with higher risk for venous thromboembolism, including Caprini score greater than 5, and patients undergoing combined procedures. In their evaluation of the National Surgical Quality Improvement Program database over a 4-year period, Rubio et al. found that in patients undergoing breast reduction, the rate of venous thromboembolism was 0.22 percent.33 Identified risk factors for developing venous thromboembolism included older patients, patients who require blood transfusion, and patients with unplanned return to the operating room. Other risk-reducing practices that are considered reasonable to consider are the discontinuation of hormonally based medications perioperatively, encouraging postoperative mobility, and the use of intermittent pneumatic compression devices.34

Use of Postoperative Drains

The evidence-based clinical practice guideline released by the American Society of Plastic Surgeons recommends that surgeons not use drains routinely in breast reduction surgery.35 This is based on multiple studies, all demonstrating that eliminating the use of drains has not resulted in higher rates of hematomas, fat necrosis, or wound healing complications, and may contribute to patient discomfort, inconvenience, and cost.36-38

Risk Factors for Postoperative Complications

Overall, major complications associated with breast reduction are quite low, especially when weighed against the benefits and patient satisfaction. A recent National Surgical Quality Improvement Program database analysis demonstrated an overall complication rate of 6.2 percent, with a major complication rate of 3 percent.39 They showed that premorbid conditions including diabetes, bleeding disorder, hypertension, steroid use, smoking, and prolonged operative times were common risk factors. Major complications were independently associated with concurrent body contouring procedure.

Smoking

Several studies have addressed smoking as an independent risk factor for complications, with mixed results. Complications include postoperative infection40 and need for reoperation.41 More recently, a National Surgical Quality Improvement Program database analysis of 13,503 cases demonstrated smoking as a risk factor for any wound complication (OR, 1.72; p < 0.001).42 In addition, there may be a relationship between urine cotinine level and incidence of postoperative wound healing problems, with abstinence or reduced intake showing healing benefits.43

Obesity

Although several published studies exist on this subject, the results are varied, with some implicating obesity and some not. A recent meta-analysis of 26 published studies demonstrated an association between increasing body mass index and risk of surgical complications, including tissue necrosis.44 Subgroup analysis in class II (>35 kg/m2) and class III (>40 kg/m2) patients demonstrated the relative risk of surgical complications to be 1.71 (95 percent CI, 1.37 to 2.12) and 2.05 (95 percent CI, 1.29 to 2.26), respectively. A recent patient-reported outcomes study examining breast reduction in patients with high body mass index showed a correlation with increasing body mass index and increasing weight of breast tissue resected.45 In addition, it did not show any difference in complication rate when stratified by body mass index (which, through its correlation to weight resected, also does not show any relationship to complication rate). Importantly, it showed that patient satisfaction was also independent of body mass index, and this combined with no increased risk of complications with increasing body mass index in this cohort would suggest that breast reduction in the obese may be justified to alleviate macromastia symptoms. This of course should not detract from the fact that weight loss for overall health is beneficial, but shows that weight loss to fit an insurance criterion may not be based on appropriate outcomes research. Further research using a validated survey tool and a larger patient cohort would be beneficial to support these results.

Ketorolac Use

As there is an increasing movement away from narcotic analgesia, nonnarcotic alternatives are being used with more frequency. These may afford patients fewer side effects related to narcotics, and allow narcotics to be used more sparingly. One such drug is the nonsteroidal antiinflammatory agent ketorolac, which can be administered intraoperatively to reduce postoperative pain. A Canadian case-controlled study demonstrated a possible association between hematoma formation and exposure to ketorolac (OR, 2.4; 95 percent CI, 0.8 to 7.4; p = 0.114); however, this was nonsignificant and likely attributable to small study numbers (n = 40 in each group).46 A study examining hematoma risk in patients undergoing breast surgery showed that in the breast reduction group (n = 378), there was no significant difference in hematoma rate between those given ketorolac (4 percent) and those who were not (3.2 percent).47 A larger U.S. study of a single-surgeon experience in 500 cases demonstrated a 1.4 percent hematoma rate, with no association between ketorolac use in the intraoperative/perioperative/postoperative periods and hematoma.48

PATIENT-REPORTED OUTCOMES

Of the tools used to assess patient-reported outcomes, perhaps the most widely used is the BREAST-Q, a validated questionnaire that has a specific breast reduction module. This module produces a numeric score, which can be compared between patients, or at different time points in a single patient’s care. Normative data have been published for the BREAST-Q, involving 1200 Army of Women volunteers who completed this module by means of Web-based software. These women were not pursuing breast reductions, and although those with a large body mass index or breast cup size had lower scores than women with a low body mass index or small cup size, their scores were higher than those of women who do present for this operation, suggesting that body mass index/cup size is not the only determinant of burden related to macromastia.49 This study was limited by the population chosen being predominantly white, educated, and wealthy, which likely does not match the demographics of the general population seeking breast reduction.

Studies that have evaluated postoperative BREAST-Q scores demonstrate that, overall, women who have undergone breast reduction have high scores in the following domains: Satisfaction with Breasts, Psychosocial Well-being, Sexual Well-being, and Physical Well-being. Women with the highest scores have greater preoperative asymmetry and hypertrophy (or both).50 Evaluation of preoperative and postoperative scores may have even more benefit in demonstrating improved quality of life and satisfaction after reduction. A Brazilian study of 107 patients approved for reduction looked at BREAST-Q scores preoperatively and 1 and 6 months postoperatively.51 They demonstrated significant improvements in the quality-of-life scales (Psychosocial Well-being, Sexual Well-being, and Physical Well-being) postoperatively, with the highest score at the 1-month postoperative visit. There was also increased satisfaction with breast appearance (mean score, 19 ± 12.9 preoperatively versus 82 ± 24.3 1 month postoperatively; p < 0.0001). A U.S. study looking at three time points (i.e., preoperatively, <3 months postoperatively, and >3 months postoperatively) demonstrated a significant improvement in BREAST-Q scores from preoperatively to postoperatively, with the improvement being maintained at both postoperative time points.52 The highest satisfaction was at greater than 3 months postoperatively, but this was not significantly different from less than 3 months postoperatively.

SUMMARY

Breast reduction remains a commonly performed procedure by plastic surgeons, and provides great benefit to those who suffer from macromastia. A variety of techniques exist, and minor variations are published annually in an effort to achieve a durable, aesthetically pleasing result while reducing associated symptoms. Evidence-based medicine and outcomes studies have allowed us to demonstrate breast reduction to be a safe, low-risk operation with high satisfaction. Our understanding of patient satisfaction through the evaluation of patient-reported outcome measures in this population may actually be the most beneficial, given that patients present desiring improvement in both physical and quality-of-life symptoms, and the evaluation of our ability to achieve this, regardless of which technique is used, is paramount to demonstrating the success of our surgery.

REFERENCES

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