Breast Reduction Technique Research Articles

Current Trends in Breast Reduction

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the technical nuances and outcome implications of the various options available in inverted-T scar breast reduction operative design. 2. Discuss the advantages, disadvantages, technical problems, best indications, and relative popularity today of vertical-scar reduction mammaplasty methods. 3. Describe the design concepts behind new techniques that seek to combine the best features of traditional inverted-T scar and vertical-scar mammaplasty methods. 4. Formulate a strategy for selection of the best reduction technique based on patient physical characteristics. Current trends in the development of breast reduction surgery include a few minor refinements in classic inverted-T scar methods but, more, the increased use of verticalscar reduction mammaplasty. The benefits of the latter, which include reduced scar burden and improved longterm projection, are attractive, although the technique itself has proved to be somewhat intuitive and more difficult to master. These shortcomings can be minimized and the technique safely learned by initially applying it to patients with minor degrees of macromastia and ptosis. New modifications and alternative approaches have been introduced recently to address the problematic areas of the vertical-scar technique. A survey of members of the American Society of Plastic and Reconstructive Surgeons was undertaken at the 1998 annual meeting to review the current role of various techniques in breast reduction. The results revealed a slow acceptance of vertical-scar methods and the dominance of the inferior/central pedicle inverted-T scar method for a wide variety of macromastia types. Other issues were reviewed; they revealed the minimal role of both blood transfusion and liposuction and that more than half of breast reductions are still performed on an inpatient basis. (Plast. Reconstr. Surg. 104: 806, 1999.)

Current Trends in Breast Reduction

Current trends in the development of breast reduction surgery include a few minor refinements in classic inverted-T scar methods but, more, the increased use of vertical-scar reduction mammaplasty. The benefits of the latter, which include reduced scar burden and improved long-term projection, are attractive, although the technique itself has proved to be somewhat intuitive and more difficult to master. These shortcomings can be minimized and the technique safely learned by initially applying it to patients with minor degrees of macromastia and ptosis. New modifications and alternative approaches have been introduced recently to address the problematic areas of the vertical-scar technique. A survey of members of the American Society of Plastic and Reconstructive Surgeons was undertaken at the 1998 annual meeting to review the current role of various techniques in breast reduction. The results revealed a slow acceptance of vertical-scar methods and the dominance of the inferior/central pedicle inverted-T scar method for a wide variety of macromastia types. Other issues were reviewed; they revealed the minimal role of both blood transfusion and liposuction and that more than half of breast reductions are still performed on an inpatient basis.

Breast Reduction Techniques and Outcomes: A Meta-analysis

Background: Although sequelae such as visible scarring often are an expected result of reduction mammaplasty, successful aesthetic outcomes depend on the surgeon’s thorough understanding of the available techniques. Objective: A literature review was undertaken to compare published outcome data for the five classical reduction mammaplasty techniques as described by Pitanguy, Skoog, McKissock, Goldwyn, and LeJour. Methods: Complication rates, patient satisfaction, and symptom relief are reviewed. Management of common pitfalls is discussed. Results: Reported complication rates range from 6.5% to 22% for reduction mammaplasty, whereas reported patient satisfaction rates range from 80% to 95%. Reported rates of symptom improvement range from 70% to 100%, with a dramatic improvement in psychological well-being. Conclusion: It is hoped that an understanding of the principles and caveats published by the originators of these five techniques will promote enhanced skill in performing reduction mammaplasty.

Breast reduction with the superior parenchymal pedicle: T-scar approach

Breast reduction for macromastia is a highly efficacious procedure with a high degree of patient satisfaction and a lowrate of complications. The T-scar superior and superomedial pedicle techniques offer safe, reliable, and easily reproducible means of breast reduction, with a versatility that works for extremely large breasts while avoiding the bottoming out of inferior/central mound methods. The procedures are simple to learn and provide satisfactory preservation of nipple sensation. Because of the smaller area of de-epithelialization and the simplicity of the resection technique, the operative time can be reduced relative to other inverted “T” approaches. They allow easy mobility of the nipple-areolar complex, and give normal-appearing nipple-areolae and lasting cosmetic results. The senior author's procedural approach to these superior parenchymal breast reduction techniques is illustrated in detail and representative clinical examples are given.

Reduction mammaplasty and mastopexy with superficial fascial system suspension.

Classic descriptions of breast reduction and mastopexy techniques have relied on dermal suspension with or without glandular shaping to contour the breast. Dermal suspension is often an unreliable and inconsistent anchor for high-tension wound repairs, resulting in unpredictable or poor scarring along with inadequate long-term lifting of the soft tissues. Hypertrophic scarring commonly occurs after dermal suspension reduction mammaplasty, being noted in 50 to 55 percent of patients at 6 months. Current studies regarding the anatomy and function of the superficial fascial system (SFS) have led to multiple applications of suspension with permanent (nonabsorbable) sutures in high-tension wound repairs of the body. As in other areas of the body, this system can be used effectively for suspension of breast-contouring procedures. Suturing the anterior SFS layer with nonabsorbable sutures (separately from the breast tissue or dermis) provides minimal tension skin repair. This should result in more predictable scarring with reduced risk of scar widening and hypertrophy. In addition, using SFS suspension in mammaplasties may result in longer-lasting contour results. The keyhole pattern used for dermal suspension techniques must be modified for SFS suspension. Reduction mammaplasty or mastopexy using these suspension wound repair techniques was performed in 109 patients (218 breasts) with a 6- to 36-month follow-up. The incidence of hypertrophic scarring was 3 percent at 6 months in this series. Suspension in mammaplasty procedures improved scar quality and provided more predictable and stable breast contours over long-term follow-up.

Standard technique of breast reduction surgery with vertical scar

In 1991, we started to use a new surgical technique for breast reduction with a single vertical scar incision as developed by Marchac, Lassus, and Lejour. The operative procedure wsa changed step-by-step according to the following significant modifications: Simultaneous liposuction is carried out only in the presence of extensive axillary fatty tissue. The undermining of the glandular tissue is limited to the extension of glandular resection. The number of glandular sutures is significantly reduced. A central fixating suture to the pectoral fascia is performed only in the presence of extreme ptosis. The positioning of the nipple-areola complex represents the final step of the reduction procedure after the resection of the glandular tissue. Based on our experience with more than 800 breast reductions, this technique is considered to be a safe standard procedure for nearly all breast sizes.

Arch reduction mammaplasty.

Arch mammaplasty is a breast reduction technique based on the inferior pedicle. It uses all the specific advantages of the inferior pedicle while avoiding the inframammary scars and dead space that occur with the inverted T technique. Arch mammaplasty has proven versatile and extremely safe, and it has a surprisingly good rate of acceptance by the patients. The scarring is aesthetically superior to that obtained with the well-accepted, inverted-T scar technique of the past.

Contralateral mastoplasty for breast reconstruction: a good opportunity for glandular exploration and occult carcinomas diagnosis.

Exploration of the contralateral breast in case of breast cancer has been advocated by many investigators, based on the incidence of contralateral cancer expected to be around 10-15%. From 1978 to 1993, 813 contralateral mammaplasties were performed to obtain symmetry in the course of breast reconstruction, including 373 mastopexies and 440 reduction mammaplasties (RMs). All these operations were performed in patients treated for a cancer of the opposite breast. Clinical and radiologic examination before the reduction mammaplasty showed tissue to be free of evident tumor. Twenty clinically and radiologically occult contralateral cancers were found in the reduction specimen (4.6%). Most of them were located in the lower and central quadrants (70%). The macroscopic size of the tumors varied from 3 to 16 mm. Twelve carcinomas were in situ, and eight cases were infiltrating. The symmetry procedure allows a good check-up of the glandular tissue of the contralateral breast at the time of the breast reconstruction, especially when there is no evidence of tumor. The different techniques of breast reduction provide specific possibilities for such exploration and should be chosen according to the preferential area that should be explored.

Obtaining projection in the amputation free nipple/areolar graft breast reduction without a vertical scar: using breast parenchyma to create a new mound.

Multiple techniques for breast reduction in the giant breast have been used. The amputation technique with the free nipple/areolar graft has been the mainstay for severe macromastia since 1921. Traditional methods for amputation of the inferior pole of the breast have created fairly flat breast mounds. Projection of the mound was enhanced by an inferior pleat with a resulting vertical scar. A new technique employing a superiorly based dermal fat flap folded back behind the residual breast to improve projection and roundness has been developed. It has not only eliminated the vertical scar but improved the shape of the mound. It has also given patients who were not previously good candidates for reduction with other techniques an option for surgery despite the presence of old scars or the need for lumpectomy in the lower third of the breast. A clinical series is presented.

Breast Reduction: The Inferior Pedicle as an Axial Pattern Flap

Mark R. Migliori, MD, Edina, MN , is a board-certified plastic surgeon. J. Bart Muldowney, MD, Edina, MN , is a board-certified plastic surgeon. The ideal breast reduction technique would allow for reliable and consistent transposition of the nipple areolar complex (NAC) with preservation of nipple viability, sensibility, and lactation potential. The ideal technique would also be applicable to all breast sizes. The blood supply to the breast is redundant, and its arterial anatomy has been well described.1 The arterial blood supply is from internal mammary, supraclavicular, lateral thoracic, and intercostal perforators. Three pairs of intercostal perforators exist from the fourth, fifth, and sixth intercostal spaces, respectively (Figure 1). The redundancy is evident in that multiple breast reduction techniques exist that rely on completely different components of this vascular anatomy to sustain the NAC. 2–6 The application of some of these techniques to the massively enlarged breast is questionable because of the unreliable viability of the NAC, and nipple grafting techniques are often recommended.7 Figure 1 Arteries and intercostal perforators through which blood is supplied to the breast. The inferior pedicle technique for breast reduction is well established as a reliable procedure. This technique has undergone several modifications. 8,9 Whereas the dermal …

Clinical applications of the central pedicle technique of breast reduction

The central pedicle technique, first described in 1985 by Hester et al, is presented as a safe, reliable, and flexible method of breast reduction that is applicable to nearly all sizes of breasts. Its greatest strengths are the maximal preservation of neurovascular structures in an open technique and the ability to precisely tailor the skin envelope after glandular reduction has been accomplished. Five years of experience at a teaching facility are presented, as well as long-term follow-up from Hester's experience.

Inferior pedicle technique of breast reduction

The inferior pedicle technique and its many variations have been described by several surgeons, and it is probably the most popular breast reduction technique in use in the United States at this time. Its advantages include ease of performance and teaching, good preservation of the neurovascular supply to the nipple, and applicability over a wide range of reduction sizes. The technique as we currently use it is presented and results are shown. It is presented as a time-tested, relatively simple, and reliable method of reduction mammoplasty.

???Pull-Through???: A New Technique for Breast Reduction in Gynecomastia

This paper reports a new technique for breast reduction in gynecomastia, removing the glandular parenchyma by pulling it through two incisions previously made for liposuction. These incisions are localized in the anterior axillary pilar area and on the right side of the inframammary fold. No complications have been reported in the 6-month follow-up visits of 11 patients. The technique makes it possible to eliminate the incision in the areolar area, avoiding its related complications. The advantage of this technique is that it removes the breast parenchyma without leaving any scars in the breast aesthetic unit, which, from a psychological point of view, has been greatly appreciated by our patients.

The Tumescent Technique for Bloodless Breast Reduction

M Beveridge, M Bell. The tumescent technique for bloodless breast reduction. Can J Plast Surg 1994;2(3):121-124. The tumescent technique for reduction mammaplasty provides a safe, reliable and inexpensive way to reduce intraoperative blood loss in reduction mammaplasty. The results of a study involving 64 consecutive patients operated on by the same surgeon are presented. Initial subjective experience with the infiltration of large volumes of very dilute anaesthetic solution deep in the breast along the planned incision lines suggested that the technique significantly reduced blood loss. To confirm this. 23 consecutive cases were operated upon without infiltration and the next 20 cases were done with infiltration of 250 mL of 0.1 % lidocaine with 1:1,000,000 adrenaline. Preoperative hemoglobin was compared with that obtained at an office visit on the seventh postoperative day. The difference in the drop in hemoglobin observed in the two groups was significant at the P<0.02 level; however, the difference was most pronounced in the group in whom a smaller volume of tissue was removed. Accordingly in the next phase of the study the volume of solution to be injected was calculated in relation to body weight. When 10 mL/kg body weight of solution was injected there was dramatically less bloodloss compared with the control group (P<0.01). Patients experienced no ill effects attributable to the injection: there were no significant postoperative hematomas nor any adverse effect on wound healing.

The "L" reduction mammoplasty.

In the breast reduction technique presented, the nipple and areola are carried on a total breast tissue pedicle elevated from the pectoral fascia. Breast tissues are resected inferior to the areola and from the pectoral aspect of the breast. The residual breast tissues are left in continuity with the nipple. Final repair is done with a medial triangular and a lateral rectangular flap. The resulting scar is "L" shaped without a medial component. The technique is applicable for breast reductions, equalizations, and mastopexies. The operation is safe, leaves satisfactory inconspicuous scars, and carries a very low incidence of complications.

The tumescent technique for bloodless breast reduction

The tumescent technique for bloodless breast reduction

Unified Breast Reduction Technique for All Degrees of Breast Hypertrophy

The different techniques for breast reduction surgery are legion. The recommendations and applications in the medical literature of specific techniques are in many instances not only confusing but misleading and fraught with danger. A good result can be achieved with any technique; however, the ability to achieve a consistently good result must be based on the surgeon's familiarity and experience with one technique. For the last nine years, the author has utilized the same basic technique for reduction of small, medium, and large breasts with uniformly excellent results judged by breast position, shape, patient satisfaction, and the absence of frequent complications. The ability to apply the same basic technique to all breasts sizes allows for the development of confidence, speed, and versatility in the successful treatment of this relatively complex problem.

Local anesthesia in reduction mastoplasty for out-patient surgery.

To perform a breast reduction under local anesthesia we need a large amount of anesthetic with lasting effects. For this I use a solution of 25 cc of lidocaine, 25 cc of bupivacaine, and 1 cc of epinephrine in 350 cc of saline solution. The bupivacaine allows a 4-6-hour operation. Once the breast is infiltrated, a great amount of anesthetic is lost in the incision, in the dissection, and in the resected tissue. Thus, a low dose remains subcutaneously to be metabolized by the liver. The serum lidocaine levels are low during these operations, as demonstrated by fluorescence polarization immunoassay. Under analgesic sedation the submammary sulcus and the retroglandular space are infiltrated, blocking the perforants of the intercostal nerves, under the areola, beneath the skin where the incision is made and where the areola is placed. This procedure has been applied to many techniques of breast reduction by modifying the infiltration under the incision lines. For hypertrophy up to 1000 g, 200-300 cc of anesthetic solution is used for both breasts at one stage, while for gigantomastia, about 400 cc of anesthetic is used, infiltrating and reducing one after the other. As the blood loss is minimal and the recovery very fast, with an appropriate adhesive bandage and a "soutien," the patient could be discharged in the afternoon. Our experience includes 94 reduction mastoplasties with local anesthesia, and also 74 other mastoplasties with equally good results. There were no patient complaints and, in general, they felt very comfortable, awakening without pain or side effects.

The superior dermoglandular pedicle approach to breast reduction.

The superior dermoglandular pedicle technique of breast reduction and its results in 193 reductions are presented. This technique offers aesthetically pleasing results, sensate nipple/areola complex, and safety. The natural shape obtained results from preservation of the superior portion of the breast tissue (where tissue is most needed) while eliminating extensive dissection within the breast. In addition, this technique offers a backup to salvage a vascularly compromised nipple/areola complex.

Reduction Mammaplasty with a Circular Folded Pedicle Technique

A personal technique for breast reduction utilizing a circular dermal-breast pedicle is presented. After a cutaneous glandular excision in the inferior pole and glandular excision in a discoid shape under the central area, the pedicle is folded on itself to produce a direct elevation of the nipple-areola complex into its new position, to enhance projection, and to act as a central support. A rational economy of scars is obtained by a central convergence of the breast tissue that stretches the breast periphery and by sutures finishing in the inferoareolar area. There the skin excess is removed to avoid scar lengthening in both the caudal and cranial directions. Evaluation of long-term results reveals maintenance of breast projection, preservation of the inframammary fold to inferior areola distance, and minimal residual scarring.