The combination of breast reduction and breast implants has received considerable attention recently.1,2 Combining the 2 operations might strike some surgeons as contradictory and even unethical.1 An increasing number of plastic surgeons, however, believe that this combination has a proper place in the plastic surgeon’s armamentarium.2 This study was undertaken to determine the efficacy and safety of this treatment combination and to compare breast measurements and patient-reported outcomes. Such a study has not been previously reported.
PATIENTS AND METHODS
There were 3 components to this study: (1) a clinical study, (2) breast measurement study, and (3) patient surveys. A breast reduction was defined as removal of ≥300 g of breast tissue from at least 1 breast.3–5
A retrospective study was undertaken among 80 consecutive women undergoing breast reduction or breast reduction with implants from 2004 to 2014. Institutional review board approval was obtained from Chesapeake Institutional Review Board, accredited by the Association for the Accreditation of Human Research Protection Programs, Inc. There were 56 breast reductions and 24 breast reductions plus implants (Table 1). No breast reconstructions or unilateral breast procedures were included.
Breast measurements were made using the system previously reported (Figs. 1–4).6 All photographs were taken by the author in the same room, with the same lighting, background, body position, and digital camera—a Nikon D80 camera (Nikon Corp., Tokyo, Japan) with a 60-mm fixed focal length lens. Mean values were used to create mammographs3 (Figs. 5, 6). Only patients with photographs at least 3 months after surgery (51 patients, 63.8%) were included in the measurement study.
All patients underwent a vertical breast reduction using a medially based pedicle7 and intraoperative nipple siting.8 A mosque-dome or keyhole preoperative pattern was not used. All breast implants were inserted submuscularly. A vertical resection was performed and is displayed in Video 1. (SeeVideo 1, Supplemental Digital Content 1, which demonstrates the vertical reduction dissection. This content is available in the “Related Videos” section of the full-text article on http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A72.) The nipple/areola site was determined after creation of the new breast mound. (SeeVideo 2, Supplemental Digital Content 2, which demonstrates the intraoperative nipple siting. This content is available in the “Related Videos” section of the full-text article on http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A73.) An inverted-T modification was used in patients in whom the vertical scar extended below the level of the new (elevated) inframammary crease. (SeeVideo 3, Supplemental Digital Content 3, which demonstrates the inverted-T modification. This content is available in the “Related Videos” section of the full-text article on http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A74; and seeVideo 4, Supplemental Digital Content 4, which demonstrates the preoperative marking, full details of the surgery and anesthesia, and the patient 24 hours after surgery. This content is available in the “Related Videos” section of the full-text article on http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A75.) All surgery was performed on outpatients in a state-licensed ambulatory surgery center using total intravenous anesthesia.4
Patient surveys were conducted by the author’s office and nursing staff. (See, Supplemental Digital Content 5, which displays the patient survey. This content is available at http://links.lww.com/PRSGO/A76.) A single-page questionnaire was administered either in person or by telephone to patients at least 3 months after surgery. The response rate was 71.4% for breast reduction patients and 66.7% for women treated with a breast reduction plus implants.
Statistical analyses were performed using IBM SPSS for Macintosh version 21.0 (SPSS, IBM Corp., Armonk, NY). Fisher’s exact test was used to compare frequencies for categorical variables. Independent t tests were used to assess mean differences between groups. Paired t tests were used to assess mean differences between matched pairs (i.e., pre vs post). Because of multiple comparisons, a P value of less than 0.01 was considered significant. An a priori power analysis was performed. To achieve 80% power, with an α level of 0.05, sufficient to detect a moderate treatment difference (d = 0.50),9 52 subjects would be needed.10
There was no significant difference in mean age, follow-up time, or body mass index between procedures (Table 1). The mean breast resection weights were significantly greater (P < 0.01) for breast reduction patients (right, 493 g; left, 489 g) than for patients treated with a breast reduction plus implants (right, 370 g; left, 368 g). The mean breast implant volume was 334 cm3 (range, 180–540 cm3). The mean operating time for a breast reduction was 2 hours (range, 88–206 minutes). Simultaneous implant insertion added 18 minutes of operating time on average.
To investigate whether patients with measurements were representative of the patient group as a whole, patients who underwent measurements were compared with patients who did not return at least 3 months after surgery and therefore did not have measurements. There were no significant differences in age, body mass index, follow-up time, implant volume, breast resection weight, or operating times between patients with photographs ≥3 months after surgery and those patients for whom these photographs were unavailable.
The overall complication rate was approximately 50%, with no significant difference between procedures (Table 2). The most common complication was delayed wound healing in 16 patients (20%). Six breast reduction patients and 1 breast reduction plus implants patient underwent secondary surgery for persistent ptosis. There were 2 seromas treated by aspiration in the office and 1 hematoma, evacuated in the operating room. No patient returned to have her breast implants removed. One patient with asymmetry returned to have 1 breast implant replaced with a larger size. There were no breast implant-related complications.
Right and left breast measurements are compared in Table 3. The right and left breast area, measured on lateral photographs, decreased in both patient groups (P < 0.001), but to a greater degree in patients who did not have simultaneous implants (P < 0.01). In both groups, the upper-pole area increased in size (P < 0.001). This increment was greater for women who also received breast implants (right, nonsignificant; left, P < 0.01). Both procedures reduced the lower-pole areas (P < 0.001). Both procedures increased breast projection (P < 0.01) and upper-pole projection (P < 0.001). Upper-pole projection increased 0.9 cm for the right breast and 0.6 cm for the left breast after reduction. With implants, the increases in upper-pole projection were significantly greater (P < 0.01), measuring 1.8 cm for the right breast (P < 0.01) and 2.3 cm for the left breast (P < 0.001). Both procedures elevated the lower-pole level (P < 0.001). The lower-pole ratio6 is defined as lower-pole width divided by lower-pole length (height) and is an indicator of the boxiness of the lower poles. Values exceeding 2.0 start to appear boxy. The overall mean lower-pole ratio was 2.0 cm, with no significant difference between procedures.
The breast parenchymal ratio6 is defined as the upper-pole area divided by the lower-pole area and is a measure of the “perkiness” of the breast. Both procedures effectively increased the breast parenchymal ratio (P < 0.001). Breast mound elevation6 represents the vertical change in position of the most projecting point on the breast. The breast mound was effectively elevated by both procedures. Areola diameters averaged 7.1 cm on the right side and 7.0 cm on the left side before surgery. These diameters were significantly reduced (P < 0.001) to 4.7 cm after surgery, with no significant difference between procedures. Nipple displacement6 is defined as the vertical distance between the nipple position and the level of the apex of the breast. For both procedures, the nipple was overelevated approximately 0.6 cm after surgery (Figs. 5, 6).
There was no significant difference in patient age or follow-up time for the surveys (Table 4). Pain ratings were slightly greater for patients who had implants (5.6 vs 4.8 on a scale of 1–10), but the difference was not significant. There was no significant difference in reported nipple numbness. Overall, 92.9% of patients were self-conscious of their breast appearance before surgery; 26.8% were self-conscious after surgery. All but 1 surveyed patient (98.2%) would repeat the surgery or recommend it to someone else. The mean result rating was 8.7 on a scale of 1–10. All surveyed patients who elected to have implants reported that they were pleased with their decision. An improvement in self-esteem and quality of life was reported by patients in both groups.
Plastic surgeons have observed that many women after a breast reduction resemble candidates for augmentation/mastopexy.2,4 This is especially true after a Wise-pattern inferior pedicle reduction, which commonly leaves the breasts looking deflated and boxy.11 Measurements confirm that an inverted-T (Wise pattern), inferior pedicle mammaplasty does not improve breast projection or upper-pole projection.11 A vertical reduction mammaplasty provides a modest boost in breast projection and upper-pole projection (<1 cm) and tighter, more circular lower poles than a Wise pattern.11 In patients who wish to restore upper-pole volume, breast implants are most effective.3 The author uses the term “breast reduction plus implants”3,4 to label this combination, avoiding the possibly confusing term “augmentation/reduction.” Measurements on standardized photographs reveal that autoaugmentation (glandular manipulation meant to simulate the effect of a breast implant) is ineffective.12
It might seem that resecting approximately 369 g of breast tissue and adding approximately 334 cm3 of volume in the form of an implant would produce a result similar to a small (i.e., 35 g) mastopexy. However, this is not the case because such a calculation does not take into account the profound changes in proportions of the upper and lower poles (that tend to cancel out when added together) created by a breast reduction plus implants. Figure 2 depicts such a patient. The morphological changes after a small-volume mastopexy are much less pronounced.3
Measurement studies reveal that postmammaplasty shape changes occurring after 3 months are minimal,3,13 indicating that at 3 months swelling has resolved sufficiently for the purpose of measurements. Thoma et al14,15 found that improved quality-of-life measures observed 1 month after surgery were maintained 1 year after surgery, justifying a relatively short follow-up period. Longer follow-up times are desirable, of course, but come at the price of a reduced inclusion rate.3
Beale et al16 recently published their experience using predominantly Wise-pattern mastopexies in combination with implants. The authors recommended small implant volumes (<200 cm3) to reduce risk. Indeed, pressure on the pedicle might tip the balance to nipple ischemia.4 A vertical mammaplasty that incorporates a medially based pedicle avoids additional tension or pressure on the pedicle caused by an implant.4 The base of a medial pedicle is mobile and rides up with the breast mound as the vertical ellipse is approximated.3,4,11 By contrast, the base of an inferior pedicle remains fixed at the inframammary fold.3,4,11 A medially based pedicle is much shorter and has a more reliable blood supply than an inferior pedicle,11 making it safer when an implant is used.4 The “minus-plus”17 combination of a vertical mastopexy and implants is synergistic.4 The often-repeated concern4,16 that a mammaplasty and implant work at cross purposes relates to the deficiencies of the Wise-pattern technique.4
A complication rate of 50% ordinarily might be considered excessive. However, this complication rate includes appearance considerations, such as asymmetry, persistent ptosis, and suboptimal scars. These problems are common after reduction mammaplasty.4 If such aesthetic issues are not included, the complication rate drops in half, to 25%. Other series15,18 reporting lower complication rates may not include such aesthetic concerns. Interestingly, patients in this study reported an overall complication rate of 25.5%, almost exactly half the rate recorded by their surgeon.
Originally, a breast reduction was considered a functional procedure, meant to reduce breast mass and elevate the nipple position. These goals were achieved by the 1920s.19–21 Today, expectations are higher and include aesthetic considerations.5 Patients having breast reduction are concerned about their symptoms, but the majority quite understandably wish to improve their breast appearance as well.5 Numerous studies document the physical benefits of a breast reduction.5 Fewer publications evaluate the patient’s perception of the aesthetic result.5 Patients consistently prefer the aesthetic result and scars of the vertical technique.22–25 Surgeons7,26,27 are aware of the flattening, boxiness, and bottoming out that can be apparent after breast reduction. These observations have been confirmed with measurements.11,12
Improving Breast Shape
Historically, the surgeon’s focus has been on nipple position.28 Less importance has been given to the relative contributions and contours of the upper and lower poles. Lateral photographs reveal that a breast reduction typically produces a linear or even concave upper-pole contour (Figs. 1, 5).11,12 Most women prefer convexity of the upper pole,29 which is the appearance produced by bras. Only breast implants are capable of providing a substantial boost in upper-pole projection.3 To provide the illusion of a breast lift (i.e., vertical movement of the breast on the chest wall), a lower-pole reduction and upper-pole augmentation are needed.3,4 This concept was first described as “minus-plus” in reference to augmentation/mastopexy by Regnault et al.17 If a patient takes her breasts in the cups of her hands and lifts up, she is interested in such breast remodeling.3
Prospective patients need to know that a breast reduction will effectively reduce breast size and eliminate the lower-pole excess, but this procedure alone will not fill out the upper pole or create convexity.3 For many women (70% in this study), such an outcome is acceptable. These patients may be satisfied that this shape can be produced by bras, or they simply wish to avoid implants or additional cost. However, there are also women (30% in this study) who want more perkiness, and it is best that they are informed of their options. Patients readily understand that the goal is still to make their breasts smaller and that this “icing on the cake” option is available to restore a more ideal shape to a breast that has been distorted by excess size and gravity.
It is reasonable to ask whether the use of implants compromises the functional benefit of a breast reduction. On a first-principles basis, one might assume that a resection of 500 g and insertion of a 300 cm3 implant is equivalent to a 200 g mammaplasty.1 This intuitive argument assumes that only total breast mass, and not its distribution, is relevant to symptoms. Surprisingly, Thoma et al14 reported that relatively small breast reductions (<400 g per breast) often alleviate symptoms, and the resection weight is not significantly related to quality-of-life improvement. These authors concluded that not just size but an unfavorable tissue distribution (i.e., glandular ptosis) may contribute to symptoms.14 Subsequent outcome studies reveal that patients with resection weights <375 g per breast30 and even <300 g per breast5 often experience physical symptoms that are relieved by surgery. The present study finds that most patients (56.3%) who elect to have implants at the time of breast reduction also experience physical symptoms. After surgery, symptoms of back, shoulder, or neck pain were reported by only 21.1% of women undergoing breast reduction alone and 18.8% of women who also received implants (difference was not significant). There was also a dramatic difference in exercise tolerance after both procedures. Overall, 78.2% of women reported difficulties with exercise before surgery and 3.8% reported such problems after surgery (0/16 for those patients treated with reduction plus implants). Indeed, the data suggest that implants do not undermine the functional benefit of reduction mammaplasty.
Limitations of the Study
This study is limited by the relatively small (n = 24) number of patients undergoing this treatment combination. Only women with a resection weight of at least 300 g from 1 breast were included. A much larger sample size would have been achieved if the cutoff had been, for example, 200 g per breast. However, using the same cutoff allows comparisons with other studies on these patient groups.3–6,11 Despite the limited sample size, there was sufficient statistical power to allow reliable conclusions at a rigorous α level of 0.01. Although no breast implant-related complications were noted during this study period, it is likely that such complications (e.g., implant deflation or capsular contracture) will occur in some patients at a future time.
Strengths of the Study
This study critically evaluates a novel treatment combination. Consecutive patients were studied. All patients were treated by the same surgeon, at the same facility, and using the same operation and imaged using standardized methods. These factors avoid confounding influences and increase the reliability of the conclusions. For example, if different surgeons treat patients with different operations (a common practice is to use the vertical technique for moderate reductions and a Wise pattern for large ones),31 it is impossible to exclude the influence of the surgeon and technique. Only by holding these variables constant is it possible to isolate the effect of implants on the surgical result. This study includes direct measurements of the aesthetic result, which are needed to make any evidence-based conclusions about surgical effects on breast shape. It also includes essential patient-reported data.
Breast reduction plus implants is a safe and effective treatment option for women with large breasts who desire restoration of upper-pole fullness. There is no increase in the complication rate or compromised improvement of physical symptoms. Recovery times are similar to breast reduction alone. Patient satisfaction is very high (93.8%). None of the patients expressed regret regarding their choice to have implants, and all reported they would have the surgery again. (SeeVideo 4, Supplemental Digital Content 4, which demonstrates the preoperative marking, full details of the surgery and anesthesia, and the patient 24 hours after surgery. This content is available in the “Related Videos” section of the full-text article on http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A75.)
I thank Lindsey Kroenke, BSN, and Sarah Maxwell, RN, for data collection, Jane Zagorski, PhD, for statistical analyses, and Gwendolyn Godfrey for illustrations.
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