Markings

A line is drawn down the center of the breast meridian line where the areola will look best (see Fig. 17.4). If a large part of the lateral breast is to be removed, the nipple–areola axis line can be moved medially as will be appropriate to the final anticipated breast width. The axis of the breast is drawn as a continued straight line below the inframammary fold by keeping it as a straight line seen through two fingers holding up the breast mound (see Fig. 17.5).

Fig. 17.5 The breast axis line is marked below the breast by lifting up on two fingers and seeing both the breast axis line on the breast and the skin below the breast through the fingers.

The new nipple site usually ends up between 19 and 22 cm from the sternal notch, and between 9 and 12 cm from the midline.

A finger on the breast is used to palpate another finger through the breast at the level of the inframammary fold, and this becomes the new nipple site (Fig. 17.4). The areolar recipient site skin excision is marked on the skin brassiere preoperatively with the patient sitting. It is drawn as a slightly horizontal oval (3.5 cm diameter horizontally, and 3.0 cm diameter vertically) as the oval will stretch to a circle when the skin brassiere flap is pulled down over the breast to the inframammary fold at the time of final closure. The areola is marked as a 4 cm diameter circle also with the patient sitting up. The area of the areolar recipient circle is deliberately marked to be a little smaller than the areola itself in order to achieve a tension free closure in the periareolar scar. The areolar recipient site is also marked smaller than the areola itself when the author uses the T scar or the vertical scar techniques.

A tension free areolar scar means a better appearing areolar scar. This scar is the most visible scar of the reduced breast (see Fig. 17.6). The areolar scar is the scar that the woman sees every day when she is naked. It is the showcase scar of the breast and should be treated as we treat the preauricular scar of the facelift; tension free and closed with care.

Fig. 17.6 Postoperatively ‘no vertical scar’ breast reduction with typical pleasing periareolar scar. The areolar opening is designed to have a slightly smaller diameter than the areola to avoid tension. There is no distortion of the inferior periareolar scar by a vertical scar, and no vertical scar on the visible breast mound. The inframammary scar is hidden in the inframammary fold below the breast mound. This is the same patient seen in Figure 17.14.

To avoid visible medial dog ears in the no vertical and T scar techniques, the medial end of the inframammary fold incision is marked to be hidden under the medial fold of the breast so that it will not be visible postoperatively (see Fig. 17.7). The lateral end of the inframammary fold incision is drawn 1 cm medial to its preoperative position because the smaller postoperative breast inframammary fold has moved medially. If the patient is overweight and has a lateral chest fat fold, the lateral scar should be kept in this fat fold crease to decrease its visibility.

Fig. 17.7 The medial end of the inframammary fold incision is marked under the medial fold of the breast so that it will not be visible postoperatively.

The inferior pedicle with a base of 8–10 cm is marked for de-epithelialization in the same way as for an inferior pedicle T scar reduction.

After the marking of the inframammary fold incision, the lower incision of the skin brassiere flap is marked on the breast mound. The center of this incision is marked at 5–6 cm below the lower border of the areola recipient site. Nice smooth curves are then drawn from this point medially to reach the medial inframammary fold incision mark (see Fig. 17.8), and then laterally to reach the lateral inframammary incision mark.

Fig. 17.8 The ideal patient has at least 5 cm of normal skin between the new areolar site and the existing areola. Notice the nice smooth curve of the black mark for the proposed inferior border of the skin brassiere flap. The red mark below it on the right medial breast would have given a boxy breast (see Figure 17.18). The medial end of the marked inframammary incision should be hidden under the medial breast mound.

If there is only 4 cm of unpigmented skin between the new areola site and the existing areola, the technique can still be used by not de-epithelializing the lower 1 cm of the inferior pedicle.

Markings are the same for both reduction and mastopexy patients. In the mastopexy patient, the entire breast is preserved except for the discarded de-epithelialized skin beneath the skin brassiere flap. In mastopexies, all of the skin beneath the skin brassiere flap will be de-epithelialized, unlike in the breast reduction patients where only the inferior pedicle is de-epithelialized.

Positioning and infiltration

The patient is placed in a supine position with the upper extremities on arm boards at about 75° from the body to avoid postoperative shoulder pain sometimes caused by the 90° position.

A solution containing 160 ml of 1/4% lidocaine and 1 : 400,000 epinephrine is mixed with 40 ml of 1/2% bupivacaine with 1 : 100,000 epinephrine. One hundred ml (half of the solution) is injected into each breast wherever skin and breast incisions are to be made. The only place where it is not infiltrated is in the intradermal plane where the skin is de-epithelialized in the inferior pedicle region. The reason for this is that the needle itself could possibly damage some of the larger subdermal veins in the pedicle.

Tourniquet and de-epithelialization

A tourniquet is applied around the base of the breast. De-epithelialization is more a matter of avulsing the skin with the help of the knife than it is cutting the epithelium off. Pulling hard on the skin to be removed greatly speeds up this part of the operation.

A knife is used through the epidermis and upper dermis in areas where skin incision healing will be required after the surgery. The coagulation cautery is used to get through the deep dermal and subdermal tissue rich in blood vessels.

Skin brassiere flap elevation

The tourniquet is released and a 1.5–2.0 cm skin brassiere flap is elevated off of the entire breast mound down to the loose areolar tissue of the chest wall (see Fig. 17.9). The lateral part of the skin flap can be made thinner (1.0 cm thick) to avoid lateral breast bulging. This lateral part of the skin brassiere flap will no longer be covering breast after surgery. Instead, it will be covering the lateral chest wall as lateral breast will either be removed in reductions or replaced from this lateral position and tacked to the chest wall medially in mastopexies.

Fig. 17.9 The skin brassiere flap is elevated at a thickness of 1.5–2.0 cm down to the loose areolar tissue of the chest wall. The skin flap can be made thinner (1.0 cm thick) laterally to avoid lateral breast bulging. The bipedicled portion of the skin flap below the areola should not be thinned to less than 1.5 cm. To best preserve nerves and blood supply, raw pectoralis major muscle should not be exposed.

The brassiere skin flap dissection is performed with a large #23 blade and carried over the whole breast so that the entire breast mound is skinned (see Fig. 17.10). This is particularly easy in a younger glandular breast where pressure is maintained on the back of the moving buried scalpel blade, constantly feeling it pressing against the gland so the sharp edge is cutting between the gland/subdermal fat junction. Large swooping cuts with the blade in this fashion make this part of the operation rapid.

Fig. 17.10 The hands are cupping the entire breast mound which has been separated from the skin brassiere flap above. Breast to be removed in this reduction case can be seen above the intact skin which outlines the inferior pedicle.

The skin brassiere flap should not be thinner than 1.5 cm in the bipedicled part below the new areolar hole in order to preserve the blood supply to that skin and fat. The areolar hole in the skin brassiere flap is made with the scalpel aimed obliquely upward (superiorly) to avoid the fat and blood supply below the areolar hole (see Fig. 17.11). There are always significant bleeders at about 10 mm in depth which provide a robust blood supply to the skin brassiere flap. We have only lost a little (<2 cm²) skin below the areolar hole on two occasions in the first year we used this technique because we thinned the bipedicled flap below the areolar hole too aggressively. This skin loss was still less than what we sometimes lost in the area of T zone necrosis in the first 15 years of the authors’ practice in which we exclusively used the T scar reduction.

Fig. 17.11 A hole is made in the skin brassiere flap to deliver the areola. The hole making blade is aimed superiorly in order to preserve the blood supply to the skin and fat below the areolar hole.

Gland excision

The breast is removed in a horseshoe-shaped pattern around the inferior pedicle just as it is in the T scar reduction. However, an attempt is made to perform most tissue removal laterally. In some of our cases, medial gland excision is not performed at all. Bulging in the armpit is a possible unwanted sequela of no vertical scar breast reduction and this can be avoided by aggressive lateral breast excision.

It is well known that the nerves and blood vessels travel in the loose areolar tissue over the muscles and in the lateral chest wall. For this reason, a good protective layer of loose areolar tissue over the chest wall and pectoralis muscle is always preserved.

After the gland excision, intraoperative breast sizers (ASSI Instruments, http://www.healthforumbuyersguide.com/company.php?id=308&company=ASSI-Accurate+Surgical) are used to help further resection for final volume adjustment to ensure that the volume of the remaining breast and skin tissue is the same on both sides before the skin is closed (see Fig. 17.12). We find this technique more accurate than trying to measure breast volume with our hands.

Fig. 17.12 The entire breast pedicle and skin flap brassiere are placed in the see-through stainless steel breast sizer, which has the closest volume to the breast being measured. The same procedure is carried out on both sides to make sure that the two breasts have the same volume before the skin is closed. Breast sizers supplied by ASSI Instruments (http://www.healthforumbuyersguide.com/company.php?id=308&company=ASSI-Accurate+Surgical). Declaration of conflict of interest – D.L. is a consultant for ASSI Instruments.

Before the breast shaping sutures are placed, take a few minutes to remove fat from the lateral skin brassiere flap and lateral chest wall so that the lateral skin brassiere flap lies flat and not bulging on the lateral chest wall.

Mastopexy cases

In mastopexy cases, the same 1.5–2.0 cm skin brassiere flap is elevated off of the breast above the de-epithelialized lower half of the breast mound. No breast or dermis is excised. Breast shaping sutures are always used.

Breast shaping sutures

After dissection, there is a large skin brassiere flap, under which a now smaller breast is placed. With both mastopexy and breast reduction, as the patient is lying on her back, the remaining breast will tend to flop laterally and fall into the lateral side of the skin brassiere. The remaining breast also tends to have little projection.

With many of the vertical scar reductions, breast shaping sutures are placed in the ‘medial and lateral breast pillars’ to increase breast projection. This type of breast shaping suture works because white breast tissue scars to white breast tissue in a rigid fashion. The more white breast tissue there is to suture to itself with breast shaping sutures, the more the scar will hold. The more yellow fat there is, the more the scar will slide. Breast shaping sutures therefore are more likely to hold and to be more useful in the younger breast where there is more breast and less fat.

Breast shaping sutures can be used with any kind of breast reduction, including the T scar and the no vertical scar reductions. We use breast shaping sutures for both no vertical scar mastopexy and reduction cases. We use 3-0 Monocryl (Ethicon, Piscataway, NJ, USA) sutures to suture the breast gland to itself to increase projection and get a pleasing shape (Figs 17.13 and 17.14). We then suture the breast to the chest wall superomedially to get it out from under the dependent lateral empty skin brassiere flap pocket until that space heals closed.

Fig. 17.13 Breast shaping sutures: loose big loops (it is important that these be loose to avoid constricting the tissue inside the loops and causing tissue necrosis) with tight knots permit breast to heal to breast in a kissing fashion to increase projection and provide a better shape in a superomedial position while the lateral empty skin brassiere flap heals to the lateral chest wall.

Fig. 17.14 A (preoperative), B (10 months postoperative), C (5 years postoperative) 28-year-old asymmetry reduction/mastopexy with removal of 320 g from (R) breast and 140 from (L) breast preoperative (top), 10 months (D) and 5 years (E) postoperative.

We use our fingers to shape the breast to achieve both projection and lateral concavity. Breast shaping sutures should not be tied too tightly to strangle the breast, nerves and blood vessels inside of the suture loop (Fig. 17.13). We therefore tie solid knots over large loose loops of breast tissue designed to just bring the breast tissue together in a kissing fashion.

Once the breast mound is attractively shaped and positioned superomedially with breast shaping sutures, it is draped with the skin brassiere flap and the skin is closed.

Sutures

We use 15–20 deep dermal 3-0 Vicryl sutures to anchor the inframammary fold incision. We start with a single suture laterally and then a single suture medially to ensure that there is no lateral or medial dog ear, and the rest of those sutures divide and divide the wound in halves until most of the wound is together.

There is more skin on the skin brassiere flap (superior) side of the wound than there is on the inframammary fold (inferior) side. The upper skin therefore has to be gathered. A running intradermal 3-0 Monocryl suture which takes longer bites on the skin brassiere flap side and shorter bites on the inframammary fold side accomplishes this task. It is important that the epidermal edges end up touching each other the entire length of the wound at the time of final closure to avoid dehiscence.

The inframammary closure is one of the more difficult parts of this operation as the skin looks gathered (wrinkled) on the superior part of the inframammary fold incision at the end of the case. We tell our patients that: (1) there will be temporary wrinkles above the inframammary fold incision that will be gone most of the time by 3 months after surgery; (2) there will rarely be a left over wrinkle; (3) these wrinkles are the price they pay to avoid a permanently visible scar down the center of the breast mound. Most patients are not concerned by the wrinkles as they are mostly hidden below the visible mound. We have never been asked to revise any of the rarely leftover wrinkles.

The tension free periareolar incision is closed with eight buried interrupted 4-0 Monocryl sutures followed by small carefully placed bites of a running intradermal 5-0 Monocryl suture.

Drains and bandages

We still use drains in most cases as they help promote the adherence of the empty lateral skin brassiere flap to the lateral chest wall. We never bring drains through a separate stab incision as this creates an unnecessary scar. We use loosely applied tapes on the skin, a generous supply of gauze, and a brassiere with adjustable straps that opens to the front.