Breast Reduction

Published on 22/05/2015 by admin

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Last modified 22/05/2015

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Chapter 17 Breast Reduction

This chapter describes in detail two main approaches to breast reduction – the inferior pedicle with an inverted T skin resection pattern and the medial pedicle with a vertical skin resection pattern. There are, however, many ways to combine skin resection patterns, parenchymal resection patterns and pedicle design.

Introduction

This chapter describes in detail two main approaches to breast reduction – the inferior pedicle with an inverted T skin resection pattern and the medial pedicle with a vertical skin resection pattern. There are, however, many ways to combine skin resection patterns, parenchymal resection patterns and pedicle design.

History of development of different techniques

In the 1970s McKissock1 introduced the vertical bipedicle breast reduction technique, which was the first procedure for breast reduction surgery that was both reliable and reproducible. Before then:

a popular breast reduction procedure was the Biesenberger2 method, but this often ended up with problems with skin flap necrosis;
Strombeck’s3 horizontal bipedicle was not easy and it was difficult to close the skin flaps over the pedicles without compression;
the lateral wedge of Dufourmentel4 was relatively easy to perform, but left the breasts with a ‘snoopy’ shape and medialized nipples;
Skoog’s5 lateral and medial pedicles were not widely known.

When it was discovered that either of McKissock’s pedicles could be severed, the inferior pedicle with an inverted T skin resection pattern became the favored method.68 It has a reliable blood supply to the nipple and areolar complex and the skin flaps close easily over the pedicle. The skin brassiere was tightened to control the breast shape. Although most surgeons around the world now use an inferior pedicle alone for the nipple and the Wise skin resection pattern9 for the skin, some still prefer the vertical bipedicle of McKissock, especially for larger reductions.

Meanwhile, the South Americans1013 and the Europeans1418 developed expertise with a vertical skin resection pattern and a vertical wedge resection of parenchyma. These techniques were used mainly for small reductions, with an inverted T skin resection pattern used for the larger reductions. Many of these surgeons used the superior pedicle19 for the nipple-areolar complex rather than the inferior pedicle, even when they chose an inverted T skin resection pattern. Many European and South American surgeons continue to use a superior pedicle, but often combine it with a Wise skin resection pattern.

Principles behind the techniques

The three main problems with breast reduction are:

Maintaining the blood supply

The breast is a superficial ectodermal structure that develops from the fourth interspace and its blood supply is superficial,20 except for the perforator through the pectoralis muscle. The perforator:

The superficial arteries comprise:

The veins do not accompany the arteries and are found separately (and seen) just beneath the dermis.

Types of pedicle

The blood supply of the different pedicles (Fig. 17.1A-E) is as follows:

The inferior pedicle must therefore be a full thickness dermoglandular pedicle to survive. In contrast, the superior, medial and lateral pedicles can all be dermal because both their venous and arterial blood supply is superficial. The innervation and the ductal system, however, will only be preserved with a full thickness pedicle.

The choice of pedicle is often a personal preference for the surgeon. All seem to have comparable postoperative sensibility. Although the lateral fourth intercostal nerve provides the main sensation to the nipple and areola, several other nerves (medial, supraclavicular) are also important. Many of the pedicles preserve the deep branch of the lateral fourth intercostal as it runs just above the pectoralis fascia. It is important to leave tissue on the fascia to preserve this nerve and protect sensation.

Free nipple grafts

Free nipple grafts are an important consideration especially if any of the other pedicles have an unpredictable blood supply,23,24 especially for the larger reductions. There is a loss of sensation, a loss of projection to the nipple, and a loss of breastfeeding potential. There is also a chance of irregular pigmentation.

Minimizing the risk of nipple necrosis

Although breast reduction is predictable and safe, there is a risk of complete nipple necrosis in around 1 in 300 patients. Some surgeons routinely use free nipple grafts, whereas many reserve these for the large reductions. The nipple is preserved with the Passot25 technique (or when a similar pedicle is used in a variation of the Robertson26 technique) where the complete inferior breast is used as a broad pedicle, and this is occasionally selected for extremely large reductions.

Skin resection pattern

The skin resection pattern (Fig. 17.2A-G) is determined mainly by the amount and quality of the excess skin.

Approaches to minimize scarring and maximize breast shape

Surgeons around the world are becoming more interested in the vertical approach, which involves the use of different pedicles with a vertical wedge resection of breast tissue. Proponents of this technique note:

The aim of further reducing scars is evident in the techniques that attempt to confine the scar to the area around the areola. The periareolar method is best suited for small breast reductions and some mastopexies.35,36 These are difficult procedures with a long learning curve. Separation of the skin flaps from the parenchyma is an essential component to achieve a good outcome.

The controversy continues between using the skin brassiere to shape the breast versus reshaping the breast and allowing the skin to redrape. Many methods rely on the skin brassiere to shape the breast and hold it in position:

Unanswered questions

Many questions are still debated by surgeons and include:

Indications

The volume of resection is not as important as suspected in improving symptoms associated with large breasts. Postoperative improvement may be as much dependent on other comorbidities such as osteo-arthritis of the cervical spine. The breast reduction will not correct any underlying disease, but can remove the weight that can aggravate the resultant symptoms. The actual elevation of the breast tissue may be as important as the amount of weight resected.

Choice of breast reduction operation

The most common skin resection patterns are the inverted T and the vertical techniques.

Vertical approach

The second most common skin resection pattern is the vertical approach. The most common pedicles are the superior and the medially based pedicles. Both the lateral and the inferior (short scar peri-areolar inferior pedicle reduction [SPAIR]30) pedicles are also used. Some surgeons take up more skin into the areola and call the procedure the ‘circumvertical’ approach.41,42 This is done to shorten the vertical scar, but does require more finesse in closing the areola without puckering and stretching.

Other techniques

Periareolar technique

For very small breast reductions, the periareolar technique can be used. This is a commonly misunderstood technique because it does not just involve suturing the skin under tension to the areola, but also involves separation of the skin from the breast tissue. The breast tissue is reduced and reformed35 with sutures or it is wrapped in various forms of mesh.36

For very large breast reductions, variations of the Passot25 technique can be used. In these cases, the pedicle is a complete inferior pedicle from medial to lateral. The upper skin flap is brought down over the inferior tissue and a cutout is then created for the areola. The upper skin flap is much longer than the incision along the IMF and a considerable amount of gathering is needed. This procedure is some-times called the ‘no vertical scar technique’ because the scar is confined to the IMF and the periareolar areas. Pribaz43 has modified the Robertson technique as a variation for the extremely large reductions. Rubin40 has developed a variation that can restore some shape for patients who have had massive weight loss.

Liposuction-only breast reduction

Liposuction-only breast reduction44,

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