Breast Reduction - Surgical Procedures

Surgical Procedures

General

Reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a woman afflicted either with macromastia (<500 gm increase per breast) or with gigantomastia (<1,000 gm increase per breast). Breast reduction surgery has two (2) technical aspects: (i) the skin-incision pattern and the skin- and glandular-tissue excision technique applied for access to and removal of breast parenchyma tissue. The incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars; (ii) the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of nerves and blood vessels (arterial and venous) that ensure its tissue viability.

The specific reduction mammoplasty procedure is determined by the volume of breast tissues (glandular, adipose, skin) to be resected (cut and removed) from each breast, and the degree of breast ptosis present: Pseudoptosis (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold); Grade I: Mild ptosis (the nipple is below the IMF, but above the lower pole of the breast); Grade II: Moderate ptosis (the nipple is below the IMF; yet some lower-pole breast tissue hangs lower than the nipple); Grade III: Severe ptosis (the nipple is far below the IMF; no breast tissue is below the nipple). The full, corrective outcome of the surgical re-establishment of a bodily-proportionate bust becomes evident at 6-months to 1-year post-opertaive, during which period the reduced and lifted breast tissues settle upon and into the chest. The post-operative convalescence is weeks long, depending upon the corrections performed; and some women might experience painful breast-enlargement during the first post-operative menstruation.

Contraindications

Breast reduction surgery cannot be performed if the woman is lactating, or has recently ceased lactating; if her breasts contain unevaluated tissue masses, or unidentified microcalcifications; if she is suffering a systemic illness; if she is unable to understand the technical limitations of the plastic surgery; and her inability to accept the possible medical complications of the procedure.

I. Inferior pedicle technique (Anchor pattern, inverted-T incision, Wise pattern)

The inferior pedicle (central mound) features a blood vessel supply (arterial and venous) for the nipple-areola complex (NAC) from an inferior, centrally-based attachment to the chest wall. The skin pedicle maintains the innervation and vascular viability of the NAC, which produces a reduced, sensitive breast with full lactational capability and function. The volume and size reduction of hypertrophied breasts is performed with a periareolar incision to the nipple-areola complex, which then extends downwards, following the natural curve of the breast hemisphere. After cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the nipple-areola complex is transposed higher upon the breast hemisphere; thereby the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the woman's person. Nonetheless, breast-reduction with an inferior pedicle, occasionally produces breasts that appear squared; yet, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia.

II. Vertical scar technique (lollipop incision)

The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision scars and a nipple-areola complex (NAC) elevated by means of a pedicle (superior, medial, lateral) that maintains the biologic and functional viability of the NAC. The increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the NAC . The vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars.

III. Horizontal scar technique

The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a nipple-areola complex (NAC) pedicle. To elevate the NAC, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the Anchor pattern). The horizontal-scar technique best applies to the woman whose oversized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed NAC. The potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold.

IV. Free nipple-graft technique

The breast reduction performed with the free nipple-graft technique transposes the nipple-areola complex (NAC) as a tissue graft without a blood supply, without a skin and glandular pedicle. The therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. The therapeutic disadvantage is a breast without a sensitive nipple-areola complex, and without lactational capability. The medically indicated candidates are: the woman whose health presents a high risk of ischemia (localized tissue anemia) of the nipple-areola complex, which might cause tissue necrosis; the diabetic woman; the woman who is a tobacco smoker; the woman whose oversized breasts have an approximate NAC-to-IMF measure of 20 cm; and the woman who has macromastia requires much resecting of the breast tissues.

V. Liposuction-only technique (lipectomy)

The breast reduction performed with the liposuction-only technique usually applies to the woman whose oversized breasts require the removal of a medium volume of internal tissue; and to the woman whose health precludes her being under the extended anaesthesia usual to surgical breast-reduction operations. The ideal lipectomy candidate is the woman whose low-density breasts are principally composed of adipose tissue, have a relatively elastic skin envelope, and manifest mild ptosis. The therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior, hence, a shorter post-operative healing period for the incision scars; the therapeutic disadvantage is limited breast-reduction volumes.