Summary

The subglandular breast reduction is a technique that has a place in breast reduction surgery in girls and younger women. It avoids any visible scarring, but relies on the ability of youthful skin to contract around a new, smaller breast mound. This technique, planned on the knowledge of the vascular anatomy of the breast, offers a new modification of the breast reduction procedure. Via an inframammary incision a ‘doughnut’ annulus of breast tissue is removed from the undersurface of the gland. The nipple–areola complex is left attached to a central core of breast tissue. When the resulting defect is closed within the breast by strategically placed sutures, the base of the gland is narrowed, the breast is projected forwards and the circumareolar and vertical scars of other techniques are eliminated.

Key Points

Patient Selection

The subglandular breast reduction relies heavily on the ability of the youthful skin to retract and ‘shrink’ around a reduced breast mound. It will not correct a ptotic breast. It is thus more suited to the younger patient with firm to hard breast tissue¹. A good guideline is that the outcome will be a smaller version of the breast shape that the patient had preoperatively (Figs 16.1–16.3) This relates especially to the relative position of the nipple to the breast mound.

Fig. 16.1 Patient 1 seen A–E preoperatively and F–J 1 year after bilateral subglandular reduction.

Fig. 16.2 Patient 2 seen A–E preoperatively and F–J 1 year after bilateral subglandular reduction.

Fig. 16.3 Patient 3 seen A–E preoperatively and F–J 1 year after left unilateral subglandular reduction.

The pros and cons of different techniques are discussed with the patient preoperatively. A patient with a preoperative ptotic breast can choose between correcting the ptosis with a pedicled technique or a subcutaneous reduction, which will leave them with some degree of ptosis postoperatively, but without visible scars. Many patients choose the subcutaneous technique on the basis of potentially fewer complications and the avoidance of visible scarring on the front of the breast. The number of girls who would opt for the more ptotic looking breast rather than have a periareolar scar is surprising.

Ideal patient selection for this technique (Table 16.1) follows the same indications as for liposuction; that is where the nipple–areola complex is sitting on the front of the breast and the breast is full and rounder in shape rather than ptotic and elongated. With ptotic breasts where the nipple–areola complex is sitting ‘underneath’ the breast rather than on the front a better shape and projection is obtained with pedicled techniques. It is the overall appearance and shape of the breast mound that is the best guide to technique selection, rather than measured distances of projected nipple areola movement. As with all breast reduction surgery the best results are obtained in those breasts requiring a smaller percentage volume reduction.

Table 16.1 Candidate selection

Indications

For the young patient in her teens and early 20s large heavy breasts have a huge effect on self esteem as well as suffering the associated physical discomforts. These young girls have difficulty getting clothing to fit, and in a country such as Australia with a warm climate and beach culture, this becomes a big issue. Buying underwear and swimwear to fit is difficult. At school and college these girls are reluctant to partake in sports. There is no doubt that a breast reduction in the young patient can bring big benefits, however it is often discouraged. This is because of concerns about loss of the ability to breast feed and also more significantly concerns about the impact of scarring.

Despite the fact that a breast reduction brings great benefit to the patient the scars are a significant downside to the operation for the surgeon as well as the patient. It is the younger adolescent patient who is most likely to be disappointed by scarring. These girls are at a time in their life when they are forming sexual relationships for the first time. Visible scars on the breast are undesirable. Pers et al² retrospectively looked at the results of 416 breast reduction patients. One-third found the resulting scars unacceptable. They found that it was the younger group of patients that made up the most of the unsatisfied patients.

Earlier techniques were based on the Wise pattern and resulted in the inverted T scars,^3–6 which were long and visible. Since then different techniques have evolved to try and minimize these scars, including vertical mammaplasty^7,8 and periareolar mammaplasty.^9,10 It is not until recently that attention has re-focussed on eliminating the circumareolar and vertical components^11–17 that are the most obvious to the patient, especially if the scar stretches or becomes hypertrophic.

As all breast surgeons know, in the young breast there is very little fat within the glandular tissue. The fat is in the subcutaneous layer and for a good aesthetic outcome this should be left intact. Not only can liposuction of the young breast be physically difficult to perform, the results are often disappointing.

The inframammary placement of the scar has fallen into disfavor, and this is undeserved. The inframammary fold is still a good place for a scar to be hidden and will become almost invisible with time provided it is kept within the confines of the fold and not under tension. It is still favored for breast augmentation surgery.

Especially in the younger patient some degree of pseudoptosis postoperatively is aesthetically more acceptable than the periareolar scar. The areola always reduces in size with a subcutaneous reduction. In young patients who are still developing sexual relationships it is more important if at all possible, to avoid any visible scarring, even at the expense of the nipple–areola complex lying lower than the ideal.

The subglandular breast reduction is indicated for this group of young women who already are vulnerable and conscious about self-image and it is important not to exchange one problem for another.

This surgery is also indicated in the young women and girls who present with breast asymmetry. The operation technique is ideally suited to this situation, where only one breast needs to be reduced, correcting the asymmetry without visible scarring (Fig. 16.3).

Anatomical Background

The dominant supply to the integument of the anterior chest is from: the internal thoracic artery medially, especially from the second and third interspaces; the lateral thoracic artery laterally; the anterior intercostal arteries inferiorly, especially from the fourth and fifth intercostal spaces in the region of the pectoralis major origin inferiorly and; from the acromiothoracic perforator and supraclavicular vessels superiorly. These vessels anastomose in the vicinity of the nipple–areola complex (Figs 16.4 and 16.5).

Fig. 16.4 Radiographic lead oxide cadaver injection studies of the arterial supply to the skin in A anterior B lateral and C cross-section views and D a venous injection study for comparison. C, D Major cutaneous perforators are highlighted as they emerge from the deep fascia, and arrows identify the nipple.

Fig. 16.5 The dominant blood supply arises from the lateral thoracic artery, acromiothoracic artery, perforators from the internal thoracic artery and perforators from the anterior intercostal arteries. The vessels course in the subcutaneous fat outside the breast gland, compressed there as the gland develops. They pass to a subareolar plexus from which the gland is supplied retrogradely. Minor vessels pass directly to the deep aspect of the gland from the anterior intercostal perforators.

The breast in the female is a modified sweat gland. Like a tissue expander, it has enlarged from the skin at the nipple into the subcutaneous tissues, elongating these vessels from their fixed skin origins and compressing them towards the periphery of the gland (Figs 16.4, 16.5A, B) to form a vascular hood. Within the boundary of this vascular perimeter there is a relatively avascular mobile plane between the undersurface of the breast and the fascia over pectoralis major. This is utilized by the surgeon when introducing a breast prosthesis, after first dividing the vascular perimeter inferiorly.

The dominant supply to the breast is by vessels which penetrate the gland from the ‘vascular hood’ following the connective tissue framework between the breast lobules. Many of these penetrating vessels arise from the subareolar network. This arrangement of blood supply provides the anatomical basis for: (i) entering the avascular plane between the breast and pectoralis major centrally, (ii) removing breast tissue from the undersurface as an annulus and (iii) leaving a central core of breast tissue supplied retrogradely by penetrating vessels from the subareolar plexus.

These penetrating vessels interconnect with each other and with a smaller network of vessels on the undersurface of the breast (Fig. 16.4C, center and Fig. 16.5B). The venous drainage has a similar arrangement to the arterial supply with major veins travelling near, but not necessarily adjacent to, their arterial counterparts (Fig. 16.4D).

Technique

Markings

The patient is marked while sitting up. The midmammary line is drawn on the breast, dropped from the mid-clavicular point through the middle of the breast mound (Fig. 16.6). The nipple may lie outside this line. The desired areas of volume reduction are marked on the breast mound (Fig. 16.7). The inframammary crease is marked. The inframammary incision is marked approximately 1 cm above this so that it will fall into the new crease position (Fig. 16.8). The inframammary crease rises postoperatively as a result of less downward pull on the lighter breast mound. The incision is placed so that the medial and lateral ends of the resultant scar will not be visible when the patient is erect. It needs to be approximately 8 cm long to give sufficient access.

Fig. 16.6 The patient is marked sitting up. The midmammary lines are marked.

Fig. 16.7 Areas of fullness are marked on the breast mound.

Fig. 16.8 The inframammary crease is marked and an 8 cm incision line marked approximately 1 cm above this, making sure it will not be visible beyond the medial and lateral limits of the new crease.

Operative procedure

The operation is performed under general anesthesia. Appropriate deep vein prophylaxis is applied. The patient is placed in a ‘deck chair’ sitting position so that the breasts assume a ptotic lie. The arms and head need to be immobilized so that the patient can be easily sat up and down during the procedure.

With the patient lying flat a local anesthetic (ropivacaine 100 ml 0.2%) is injected in a ‘u’ around the periphery of the breast mound.¹²

An incision of about 8 cm is made in the marked position. The subglandular plane is entered and a blunt dissection made, as in a submammary augmentation (Fig. 16.9). With the fingers in the subglandular plane the breast skin is dissected off the gland in a plane deep to the subcutaneous fat and on the ‘breast capsule’ – in the mastectomy plane. A ‘pushing’ technique with scissors is used. This plane is well demarcated in the young breast (Figs 16.10 and 16.11A). This is continued from inferior to the nipple–areolar complex in a circular fashion to surround the complex (Fig. 16.11B). This dissection is not taken under the nipple–areola complex. Lighted breast retractors are used to facilitate hemostasis. The blood supply is preserved outside this dissection (Fig. 16.11C).

Fig. 16.9 Eight cm incision through the subcutaneous fat 1cm above inframammary fold. Subglandular pane dissected bluntly.

Fig. 16.10 In the young patient the plane between subcutaneous fat and underlying breast glandular tissue is clear.

Fig. 16.11 A The subcutaneous fat is freed off the underlying gland outside the areola using a pushing technique with open scissor tips. B Schematic diagram showing area of subcutaneous dissection ‘loosening’ gland from overlying subcutaneous fat. C Schematic diagram showing plane of dissection in relation to arterial blood supply.

The resection is performed taking out an annulus of tissue from the underside of the breast. The breast is envisaged as three concentric rings:

1. an outer rim

2. an intermediate annulus to be resected

3. an inner core of breast tissue containing the nipple–areola complex.

The intermediate annulus is removed from the undersurface of the breast. The outer rim is left so as to avoid damage to the vessels and to leave sufficient subcutaneous fat and breast tissue to avoid skin dimpling. The tissue is removed piecemeal with more tissue taken from the lateral side (Fig. 16.12A,B). Lighted breast retractors are used to facilitate hemostasis. Depending on the breast shape, an asymmetrical annulus or only a portion of an annulus, can be removed (Fig. 16.12C) The breast can be partially everted through the wound allowing selection of the areas to be removed (Fig. 16.12A) This degree of flexibility is advantageous when operating on the asymmetrical breast to match it to the other side.

Fig. 16.12 A, B, C Breast tissue is pulled down from the deep surface of the gland and resected piecemeal removing an intermediate annulus. A central core is left behind the areola and outer rim of breast tissue left behind. The tissue is removed piecemeal allowing asymmetrical resection as required.

Eliminating the dead space created by removing the intermediate annulus narrows the base of the breast. The outer rim is approximated to the inner core with non-absorbable sutures (clear 0 Prolene; Johnson and Johnson, Somerville, NJ) from the outer rim to the prepectoral fascia (Figs 16.13 and 16.14).

Fig. 16.13 The breast base is narrowed and the dead space approximated by strategically placed sutures of 0 Prolene from the lateral rim to the prepectoral fascia.

Fig. 16.14 The breast base is narrowed and the dead space approximated by strategically placed sutures of 0 proline from the lateral rim to the prepectoral fascia.

The central core is projected forward on the narrowed breast base. This brings the lateral breast base up and forward from its old position, to make a new narrowed base.

It is worth sitting the patient up a little at this stage while supporting the breast mound to see that the resection looks even and to have some idea of the outcome in terms of volume and shape. There is much redundant outer breast skin and fat which makes this judgment only approximate.

As long as careful attention is paid to hemostasis there is no increased risk of hematoma formation. Drains are not routinely used. The wounds are closed with 3/0 Monocryl (Johnson and Johnson) dermal and subcuticular sutures. The skin is then allowed to ruche up over the new breast mound. It is taped in place with Hypofix (Smith and Nephew, Hull, UK) tape.

The taping of the breast mound to redistribute the skin is critical. 10 cm wide tape is placed over the lower pole to support the breast (Fig. 16.15A) Short strips of tape 5 cm wide are then placed in a radial fashion from around the nipple overlying the skin gathers (Fig. 16.15B). Further 10 cm wide tapes are then placed over the breast mound to give a semirigid support (Fig. 16.15C). The tapes are removed 2 weeks postoperatively and the patient wears two surgical bras, one outside the other, for a further 6 weeks both day and night. Occasionally it may be necessary to extend the period of taping to 4 weeks if when the initial tape is removed one feels that the breast would benefit from further tape support. The skin will continue to take up and the shape improve over a matter of months.

Fig. 16.15 The breast is taped to support the shape. A The wound is covered and base supported with a 10 cm strip. B Radial taping from the areola with 5 cm strips. C Further support with 10 cm strips.

Postoperative Care

For the first 10 postoperative days oral analgesia is provided and taken regularly. After 2 weeks the tape is removed. We encourage the patients to remove the tape at home using baby oil and a warm shower before coming in. Allowing plenty of time averts what can otherwise be an uncomfortable experience for both patient and staff. It is wise to warn the patient of the wrinkled, misshapen, non-aesthetic appearance of the breast at this stage. If the skin looks as if it needs further shrinkage then the breast can be retaped for a further couple of weeks. Double bras are continued to be worn day and night for a further 6 weeks after cessation of the tape. The skin take up will continue over the ensuing months, and the final result will not be evident for 12 months.

Pitfalls and How to Correct

One of the great advantages of this technique is minimal complications. Postoperative bleeding is the main risk. In the early evolution of the technique there were a few hematomas, but this has now been avoided by not infiltrating with hemostatic solution preoperatively and meticulous hemostasis during surgery. The cut vessels tend to retract back into the tissue which is being pulled down into the wound for access. As long as one is mindful of this, hemostasis can be maintained with coagulative diathermy.

A poor outcome will ensue when the skin does not retract as much as one wishes. It is important post operatively to use tape to encourage skin take up and to allow a full 12 months. If after 12 months the skin looks loose on the breast mound with the nipple sitting lower than the ideal then a surgical revision is then required to remove the extra skin. This is a minor procedure in which a periareolar skin resection is performed under local anesthetic (Figs 16.16 and 16.17). With good patient selection the likelihood of needing this revision is minimal.

Fig. 16.16 Not enough skin take-up corrected by periareolar skin resection under local anesthetic.

Fig. 16.17 Not enough skin take-up corrected by periareolar skin resection under local anesthetic.

Intraoperative judgment of the amount of tissue to resect is not easy when correcting asymmetry (Figs 16.18 and 16.19). One has to make a good estimate preoperatively of the volume of tissue to be resected and where from. The weight resected is always less than in a pedicled reduction for an equivalent volume reduction. Sitting the patient up intraoperatively while supporting the breast mound helps in the assessment.

Fig. 16.18 Underestimation of volume to be resected in case of right unilateral subglandular reduction for asymmetry.

Fig. 16.19 Underestimation of volume to be resected in case of right unilateral subglandular reduction for asymmetry.

The inframammary scar, because it is under no tension, heals in the same manner as an inframammary augmentation scar without hypertrophy. As the nipple–areola complex is in continuity with the integument, to date there have been no healing problems in the author’s experience. There have also been no reported incidences of fat necrosis that the author is aware of, likely to be due to the good vascularity of the technique.

In a study done 89% of patients had normal nipple sensation after 12 months. There have been no studies done looking at the postoperative incidence of breast feeding with this technique, but there are anecdotal cases where breast feeding has been successful. Theoretically, as the lactiferous ducts are not divided and some glandular tissue is left centrally there should be potential for lactation.