Single-Stage Suction-Assisted Lipectomy with Dermal Mastopexy: An Alternative Procedure in Repeated Reduction Mammaplasty with Questionable Nipple-Areola Complex Vascularity.

Abstract

A majority of malpractice claims in plastic surgery involve complications following breast surgery.1 Nipple-areola complex necrosis is a devastating complication in reduction mammaplasty secondary to compromised vascular supply. The risk of nipple-areola complex necrosis increases in repeated reduction mammaplasty, particularly when the previously used technique is unknown and operative reports are unobtainable. The appropriate technique for repeated reduction mammaplasty remains controversial, as several approaches have been advocated in the literature.2 Many of these techniques involve full-thickness incisions and wide tissue excision for volume reduction, and thus carry the intrinsic risk of nipple-areola complex necrosis due to violation of the underlying vasculature. Suction-assisted lipectomy with dermal mastopexy is a novel technique for repeated reduction mammaplasties to preserve nipple-areola complex vasculature and sensation. An inverted-T de-epithelialization is marked preoperatively (Fig. 1). Each breast is instilled with 1 liter of tumescent solution consisting of 1 liter of Ringer’s lactate with 1:1,000,000 epinephrine and 50 cc of 1% lidocaine. De-epithelialization is undertaken while the breast is tumesced, and the raw surface provides access points for suction-assisted lipectomy. Liposuction is accomplished using a MedGyn Rigid Currette size 7 (MedGyn Products, Addison, Ill.). After suction-assisted lipectomy, dermal mastopexy is completed with interrupted sutures, imbricating the dermal surface.Fig. 1.: Intraoperative views of suction-assisted lipectomy with dermal mastopexy. The midline axis, inframammary fold, nipple-areola complex, distance from sternal notch to nipple, and incision lines were marked along the breast (left). There was much less excess skin in repeated reduction mammaplasties than in primary reductions, and the nipple-areola complex rarely had to be moved more than a couple of centimeters. De-epithelialization of the breast then provides access for suction-assisted lipectomy (right).Eleven suction-assisted lipectomy with dermal mastopexy procedures were performed from 2008 to 2019. The median patient age was 43 years (±9.9 years) and the median time between reductions was 14.5 years (±5.9 years). Average total volume reduction per breast was 800 cc (±200 cc). There were no intraoperative complications in the cohort. Two patients had postoperative complications of wound dehiscence requiring eventual return to the operating room for hypertrophic scar revision. After a follow-up period of 6 months, all patients reported intact nipple-areola complex sensation, and nipple-areola complex vasculature was preserved in all cases. All patients reported decreased symptoms associated with macromastia, such as rashes and back pain. All patients reported satisfaction with their final breast size and symmetry. Aside from aesthetic considerations, any breast reduction must also take oncologic considerations into account. Preoperative imaging was performed in most of our patients to identify malignancies and serve as a comparative baseline for future mammograms. Reduction mammaplasty with liposuction has been shown to trigger deep intraparenchymal calcification development.3 Most of these changes are macrocalcifications, however, and are rarely confused with malignant-appearing microcalcifications when reviewed by experienced radiologists.3 The evidence suggests that liposuction with dermal mastopexy does not interfere with detection of malignancies any more than traditional techniques.4 In this small review, we show that repeated reduction mammaplasty can be as complication-free as the initial reduction with nipple-areola complex preservation. Furthermore, this approach can be critically useful in the setting of unknown prior surgical techniques. Limitations to our study include our small sample size and lack of a standardized comparison group. Furthermore, while suction-assisted lipectomy is a favorable approach for breasts composed largely of fatty tissue, this technique is not appropriate for breasts composed of mostly glandular tissue.5 Therefore, suction-assisted lipectomy with dermal mastopexy may offer a significant advantage for older patients due to the progressive fatty involution of breast tissue with age. DISCLOSURE The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work.