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Abstract

Sir: The article “Does Knowledge of the Initial Technique Affect Outcomes after Repeated Breast Reduction?” by Ahmad et al. 1 was reviewed at the University of California, San Francisco plastic surgery monthly journal club meeting. We have questions pertaining to (1) the procurement of operative records from the surgeon who performed the original reduction mammaplasty and (2) the standard for and application of determining “outcomes.” First, between 1998 and 2010, the authors operated on 12 patients whose primary surgery was performed by a surgeon other than themselves. On none of these were the authors able to recover the original records, despite the fact that there was “an attempt to obtain the operative report describing the primary breast reduction technique.” Were valid authorization forms obtained from patients requesting the primary surgeon to release records to the authors obtained and rejected? The accepted standard for good patient relations is that a physician should supply records. If a patient refuses to sign such a request, one might question the patient’s forthrightness, especially if advised that to render the best care most physicians feel that having all the pertinent information is important, particularly in secondary surgery. Second, we feel that the term “outcomes” embraces both safety and efficacy. The article lends credence to the safety of their procedure vis-à-vis nipple-areola survival. They state that “patients underwent repeated breast reduction for recurrent hypertrophy, inadequate volume reduction, and significant postoperative breast volume asymmetry.” We note an absence of concern that the nipple-areola complex was too low or that the inframammary scar was unacceptable. Figures 4 and 5 show a nipple-areola planned elevation of only 1 to 2 cm; therefore, it is not surprising that circulation was adequate. Furthermore, one would not expect those patients on whom the authors did not perform a circumareolar incision to experience nipple-areola necrosis regardless of the orientation of the original pedicle. Figures 3 and 6 appear to be the same patient. We noted that even though there was no circumareolar incision, the removal of the “wedge” of breast tissue apparently resulted in bilateral loss of nipple projection visible on all three photographic views. We speculate that the patient most likely had an inferior pedicle procedure initially and that the secondary procedure resulted in denervation of the nipple. The oblique views in Figure 6 also show persistence, or recurrence, of pseudoptosis after revision. We recognize that the vertical skin markings with a variety of pedicles is an effective and excellent reduction and mastopexy technique; however, in those patients who already have an inframammary scar, we have found it helpful to correct pseudoptosis by resecting skin in both the vertical and horizontal directions as illustrated below. An additional benefit can be an apparent lowering of the nipple-areola complex. Judicious glandular resection with a goal of original pedicle conservation is performed as required to reduce volume. Liposuction is reserved for correction of discrete areas of prominence (Fig. 1).Fig. 1: Correction of pseudoptosis using vertical and horizontal skin excision.Based on our own experience, we respectfully suggest that every effort should be made to obtain the orig inal operative note (in the vast majority of cases, we have been able to do so). Criteria in addition to nipple-areola survival should be considered in judging the “outcomes” of repeated breast reduction surgery. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mauricio Kuri, M.D. Gilbert P. Gradinger, M.D. Department of Plastic Surgery University of California, San Francisco San Mateo, Calif.