Wednesday, December 24, 2008

Do Overs

Earlier this year I saw a breast reduction patient whose surgery I did early in my career and with her permission I am sharing this.

I did her breast reduction using an inferior pedicle technique for the safety of the blood supply to the nipple-areolar complex. She came back to see me because her nipple “sits too high”. Actually, the nipple doesn’t set too high. The distance from the sternal notch to the nipple (SN-N) is the correct length for her height. She has what we call “bottoming out”.

Notice how the breast tissue seems to have slipped down the chest and no longer sits behind the nipple/areolar complex.

When I saw her again, I couldn’t help but think about how I would do her surgery differently today. I am at a different point on the learning curve than I was then, so I have tried not to be too harsh on myself. Still, I would have used a superior-medial pedicle. That simple change would have (most likely) kept her from this visit. Superior-medial pedicles rarely if ever “bottom out”.

Another thing I would have done differently is the incision/scar. I used the Wise–pattern and she has an anchor-shaped (or inverted T) scar with a periareolar circle. She has a long (looong) inframammary scar. Today, even when I do need to use the Wise pattern incision, I can often half the length of that inframammary scar. Today, I do many more using just the vertical scar and periareolar circle so there is no inframammary scar. That technique has really only become popular and accepted as safe in the last 10 years.

I can’t go back and “do over” her surgery from the very beginning with my knowledge and skills of today. Fortunately (and I do feel blessed that she understands that), she doesn't blame or fault me. It is me doing the soul searching and wishing I could go back.

The best I can do for her is correcting the “bottoming out” which I find easy to do. I just wish there were no need for it.

To correct the bottoming out, I mark (as can be seen in the photos above) the true inframammary crease. I measure 6-7 cm from the nipple and plan a wide elliptical excision of the inframammary scar. In this woman’s case, the old scar fell near the center of the ellipse. I then excise skin only, do a minimal undermining superiorly, reshape the breast tissue with some heavy vicryl sutures, and then close the incision. Here are some post-procedure photos.

1 comment:

Christine said...

I happened across this post this morning and I have a question or three for you -

About five years ago, I had a breast reduction surgery using the same technique you originally used on this woman (going from a 38 DDDD to a 38C), and I "bottomed out" fairly quickly after the procedure. After some wild weight fluctuations, I now weigh 40lbs less than I did then, which doesn't help either... especially since I have very non-resilient skin. Basically, I look even more sad and deflated (with nipples that appear too high) than your patient here. At the age of 25, it's a bit depressing. :( I think a revision is something I'd like to do eventually if I can afford it, but fortunately I look fine as long as I have a bra on, so I can live with it a while longer, I suppose.

How does the cost and recovery time for a procedure like this compare to the original operation? It seems like it would be a faster (cheaper?) surgery with an easier recovery. How often do you see this situation in your post-breast reduction patients? Perhaps this is wishful thinking, but have you ever had an insurance company cover a surgery like this?

Sorry to pester you with questions... it's just something that bothers me whenever I am undressed or have to go braless. I just look... weird.

If you're willing to indulge me, you can email me at , in lieu of responding via comment, if you would like. Thanks. :)