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.