Wednesday, December 19, 2007

Reduction Mammoplasty

Breast reduction (or reduction mammoplasty) is an operation designed to reduce and reshape large breasts. It is a surgical procedure designed to help reduce and in many cases eliminate, the pain and other symptoms associated with large breasts. Discomfort associated with large breasts can include chronic back, neck, and shoulder pain, as well as painful shoulder grooves from bra straps. It can also include chronic rashes under the breasts in the inframammary fold. These are the medical reasons to have a breast reduction. Most insurance companies will cover breast reduction surgery done for medical reasons. Be sure to check your policy.

Non-medical reasons may include difficulty finding a bra that will fit. also limit women’s abilities to perform routine daily activities and may cause significant emotional distress. By reducing breast size, breast reduction surgery can relieve many of these symptoms. It can also make it easier to perform routine daily activities and exercise more comfortably.

Some Historic Aspects of the Procedure

In 1922 Thorek introduced the free nipple grafting technique. A significant advance was the introduction of the pedicled nipple-areolar transposition, which improved nipple survival, provided a way to correct ptosis (sagging), and gave a possibility of breast feeding post-reduction (by leaving some of the gland tissue connected to the ducts). Schwarzmann introduced the concept of maintaining the dermal attachments to the nipple as a means of preserving or protecting its blood supply in 1937. This remains important in every procedure used today.

In 1956, Robert Wise published on his experience with a refined pattern that he had previously designed in the form of a key-hole. he emphasized the need for accurate preoperative marking and  provided a pattern for the "key-hole". This Wise pattern has been the workhorse for skin incision for breast reduction for several decades. It leaves an anchor-shaped (or inverted T) scar with a periareolar circle, a vertical scar in the midline of the inferior mammary hemisphere, and a curvilinear scar along the inframammary fold that follows the curved shape of the inferior pole of the breast. (photo credit)

In 1972, Paul McKissock modified Wise's technique by increasing the length of the vertical limbs of the design to try to compensate for the flat lower pole that was being achieved. It is now recognized that McKissock's technique tends to often result in the opposite effect, which is a "bottoming-out" and is not very well tolerated by patients and surgeons.

The vertical scar incision pattern was originally designed by Claude Lassus in 1964 and reported in 1970, with the problem of the inferior portion of the vertical scar ending up extending below the inframammary fold. Lassus corrected this by adding a small horizontal scar along the inframammary fold. Later on, he realized that the small horizontal scar ended up migrating up  toward the lower hemisphere of the breast. He subsequently redefined the pattern of skin excision until achieving one that left only a vertical scar above the inframammary fold. This is the skin incision that is used in the so-called Lejour technique (Madeleine Lejour, MD 1994).   (photo credit)

 

Each technique has advantages and disadvantages. The superior pedicle method (which involves the resection of the medial, lateral, and inferior portions of the breast tissue) was originally described by Daniel Weiner in 1973. It gained more popularity in Europe, initially, than in North and South America. It was thought to put at risk the sensation of the nipple-areola complex because of the belief that it transected the lateral branches of the fourth intercostal nerve. The sensory branches to the nipple-areola complex are now known to run deep at the level of the chest wall and perforate superficially through the breast tissue to reach to nipple areola complex. For this reason, it is good to keep some tissue on the pectoralis muscle/chest wall as it preserves the nerve supply to the nipple-areola complex and, thus, its sensation.

Today, the tendency is towards Vertical Scar Techniques rather than the ones that use the Wise pattern procedures. However, with truly large (greater than 1000 gm resections) breasts or Grade III ptosis with nipple to inframammary fold lengths greater than 20 cm that is not always possible or advisable. There are times when free nipple grafts are still the best option (safest).  (photos credit)

  

There is also interest in

liposuction reduction mammoplasty. Many insurance companies will not pay for this type of reduction mammoplasty. Liposuction reduction mammoplasty is contraindicated in breasts that are mostly glandular and in the presence of ptosis and/or poor skin elasticity. The only "lift" gained from this type of reduction depends on the skins elasticity.

 

Complications

In general, postoperative complications are seen more commonly in patients with large resections, obesity, history of tobacco use, and young age. Some evidence suggests that wound dehiscence, fat necrosis, and infection are less common in patients who undergo the Lejour technique than in those who undergo the Wise pattern and inferior pedicle techniques. However, some asymmetry, particularly along the bottom edge, tends to be more common in patients who undergo the Lejour technique; revision rates can be up to 10%. Liposuctioning of the breast has not been shown to increase the rate of local complications

Nipple necrosis

The incidence of complete nipple necrosis is 0.5%. Partial nipple necrosis occurs in a similar percentage of patients.

Infection

As with any surgery, infections can occur. They are not common (0.5-10%) in breast reduction surgery. Most surgeons give perioperative cephalosporins which has been shown to decrease the rate of infections.

Revisions

The revision rate will vary depending on the procedure done (from 1-10%). It may be done for puckers (vertical scar reduction) that may need to be excised. Puckers are often more of a problem of residual subcutaneous tissue (along the inframammary crease region) than of excessive skin. Or to correct an asymmetry problem. Or to correct hypertrophic scars.

Fat necrosis

Fat necrosis is usually minor and related to what is thought to be parasitic fat along the margins of the pedicle. Minor amounts of fat necrosis can be missed unless the breast is specifically examined for this complication. No treatment is needed except for explanation and reassurance. Patients do not usually require surgery to treat this complication.

Wound dehiscence

Delayed healing may occur and is most likely to be a problem at the inferior end of the vertical incision, where skin gathering is performed in the vertical scar reduction. It is common in the Wise-pattern reductions at the "corners" where the "T" forms. Care must be taken to close the vertical incision loosely and with superficial bites so that the skin is not constricted. This is more common with large reductions and in the obese patients.

Hematoma

Hematomas are usually minor when they occur and can be treated conservatively. It is very rare to have a major hematoma after a breast reduction. Some plastic surgeons routinely use drains. Many of us don't.

 

 

REFERENCES

Breast Reduction, Lejour by Antonio Espinosa-de-los-Monteros, MD -- eMedicine Article

Breast Reduction, Simplified Vertical by Elizabeth J Hall-Findlay, MD -- eMedicine Article

Breast Reduction, Inferior Pedicle by Susan E Downey, MD -- eMedicine Article

A preliminary report on a method of planning the mammoplasty; Wise RJ; Plast Reconstr Surg 1956 May; 17(5): 367-75

Breast reduction: evolution of a technique--a single vertical scar; Lassus C; Aesthetic Plast Surg 1987; 11(2): 107-12

Reduction mammaplasty with a vertical dermal flap; McKissock PK; Plast Reconstr Surg 1972 Mar; 49(3): 245-52

Vertical mammaplasty and liposuction of the breast; Lejour M; Plast Reconstr Surg 1994 Jul; 94(1): 100-14

Insurance Coverage: A Patient's Guide -- American Society of Plastic Surgeons Website

Breast Reduction, a Guide for the Patient –ASPS

 

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6 comments:

Femail doc said...

I have yet to meet a truly big-breasted woman who regrets her decision to have a reduction mammoplasty. Even the very few who've had a difficult post-op recovery.

Dr. Shock said...

Holy smoke that is a lot of information written down very well. I know you use this knowledge probably every day but it is very informative.
Regards Dr Shock

rlbates said...

Femail Doc, so true -- mostly. I happen to have met a couple, though maybe they just wished they had used a different surgeon.

Dr Shock, thanks.

Dreaming again said...

I was told, by someone, that they never met a woman who was happy they'd had it done. I thought that odd, knowing what it was like ... also the research I'd done on line; it seemed like a high satisfaction rated surgery.

It took me a couple of hours to realize, she was my 'bra consultant' at the specialty shop where I HAD to buy my bras. She had a vested interest in saying it was not a good surgery. (no more need for $65 bras from them!)

I have only met/talked to women who wished they'd done more research on their surgeon ..or wished they'd had more removed ... not a one who was not glad she'd done it.

My biggest disappointment post reduction ... finding out that there is no such animal as a truly comfortable bra! ;)

I think, from reading your article, I had the 'wise' proceedure. (I knew at the time exactly what it was, but I've slept since then ;) ..)

Anonymous said...

I had breast reduction sugery about 5 days ago and 3 days afte the surgery I developed what the Dr. says sounds like a hematoma. I went back to see him, but was only able to see the 3rd year resident who workd with him. I have to go back on Tues. and was wondering should I ask him to drain this? I have been so depressed, crying and feeling like I should not have done this surgery. Some of the swelling has gone down, but it is still rather large. I feel like I should have just left my breasts like they were because now I am worse off than before. My Dr. told that that it will go away on it's own, but when? I feel like I made a huge mistake. As a plastic surgeon, could you give me some advise as to how I should be feeling and what I can expect? My sugeon just keeps telling me that it will be ok and will go away on its own.

rlbates said...

If it is a large hematoma, ask him to aspirate it. That way the swelling goes away faster. As for the "regret for having the surgery", now is not the time to decide that. See how you feel at one month or at two month post surgery.