Breast reduction: the correction of macromastia and severe breast ptosis; pre-operative aspects (left); post-operative aspects, the corrected breasts, the lifted bust.
Reduction mammoplasty (also breast reduction and reduction mammaplasty) is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the woman's body, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold -- physical, aesthetic, and psychological -- the restoration of the bust, of the woman's self-image, and of her mental health.
The woman afflicted with macromastia presents heavy, enlarged breasts (>500 gm per breast per the Shnur Scale) that sag and cause her chronic pains to the head, neck, shoulders, and back; an oversized bust also causes her secondary health problems, such as poor blood circulation, impaired breathing (inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassière-strap indentations to the shoulders; and the improper fit of clothes.
In the woman afflicted with gigantomastia (>1,000 gm increase per breast), the average breast-volume reduction diminished her oversized bust by three (3) brassière cup-sizes. The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations that a bodily-disproportionate bust imposes upon a woman; thereby it improves her physical and mental health. Afterwards, the woman's ability to comfortably perform physical activities previously impeded by oversized breasts improves her emotional health (self-esteem) by reducing anxiety and lessening psychological depression.
The medical history records the woman's age, the number of children she has borne, her breast-feeding practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information, are her history of tobacco smoking and concomitant diseases, breast-surgery and breast-disease histories, family history of breast cancer, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness.
The physical examination records and establishes the accurate measures of the woman's body mass index, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of breast ptosis, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the nipple-areola complex (NAC), and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight, kyphosis (excessive, backwards curvature of the thoracic region of the spinal column), skin irritation, and skin rash affecting the breast crease (IMF).
A woman develops large breasts usually during thelarche (the pubertal breast-development stage), but large breasts can also develop postpartum, after gaining weight, at menopause, and at any age. Whereas macromastia usually develops in consequence to the hypertrophy (overdevelopment) of adipose fat, rather than to milk-gland hypertrophy. Moreover, many women are genetically predisposed to developing large breasts, the size and weight of which often are increased either by pregnancy or by weight gain, or by both conditions; there also exist iatrogenic (physician-caused) conditions such as post-mastectomy and post-lumpectomy asymmetry. Nonetheless, it is statistically rare for a young woman to experience virginal mammary hypertrophy that results in massive, oversized breasts, and recurrent breast hypertrophy.
The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the overdevelopment of the milk glands or of the adipose tissue, or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild (<300 gm) to the moderate (ca. 300-800 gm) to the severe (>800 gm). Macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging, breast ptosis that is determined by the degree to which the nipple has descended below the inframammary fold (IMF).
Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy; yet a weight-reduction regimen for the over-weight woman can alleviate some of the excessive size and volume of her abnormally enlarged breasts. Physical therapy provides some relief for sufferers of neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chafing, infection, and bleeding.
The traditional, surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; yet it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar -- around the nipple-areola complex (NAC), where the dark-to-light skin-color transition hides the surgical scar.
A reduction mammoplasty to re-size enlarged breasts and to correct breast ptosis resects (cuts and removes) excess tissues (glandular, adipose, skin), overstretched suspensory ligaments, and transposes the nipple-areola complex (NAC) higher upon the breast hemisphere. At puberty, the breast grows in consequence to the influences of the hormones estrogen and progesterone; as a mammary gland the breast is composed of lobules of glandular tissue, each of which is drained by a lactiferous duct that empties to the nipple. Most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules -- except during pregnancy and lactation, when breast milk constitutes most of the breast volume.
Surgically, the breast is an apocrine gland overlaying the chest -- attached at the nipple and suspended with ligaments from the chest -- which is integral to the skin, the body integument of the woman. The dimensions and weight of the breasts vary with her age and habitus (body build and physical constitution); hence small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750-1,000 gm. Anatomically, the breast topography and the hemispheric locale of the nipple-areola complex (NAC) are particular to each woman; thus, the desirable, average measurements are a 21-23 cm sternal distance (nipple to sternum-bone notch), and a 5-7 cm inferior-limb distance (NAC to IMF).
The arterial blood supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery (from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries. Drainage of venous blood from the breast is by the superficial vein system under the dermis, and by the deep vein system parallel to the artery system. The primary lymph drainage system is the retromammary lymph plexus in the pectoral fascia. Sensation in the breast is established by the peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerves, and thoracic spinal nerve 4 (T4 nerve) innervates and supplies sensation to the nipple-areola complex.
In realizing the breast-reduction corrections, the plastic surgeon takes anatomic and histologic account of the biomechanical, load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (Poisson's ratio of ~0.5).
Reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a woman afflicted either with macromastia (>500 gm[clarification needed] 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-operative, 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.
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. Additionally, recent research has indicated that mammograms should not be done with any increased frequency in patients undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction.
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.
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.
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.
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, requiring much resecting of the breast tissues.
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.
The medical treatment records for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the oversized breasts, the sternal-notch-to-nipple distances, and the nipple-to-inframammary-fold distances. The woman is instructed about the purposes of the breast reduction surgery, the achievable corrections, the expected final size, shape, and contour of the reduced breasts, the expected final appearance of the breast reduction scars; possible changes in the sensation of the nipple-areola complex (NAC), possible changes in her breast-feeding capability, and possible medical complications. The woman also is instructed about post-operative matters such as convalescence and the proper care of the surgical wounds to the breasts.
Incision-plan delineation -- To the breasts of the standing patient, the plastic surgeon delineates the mosque dome skin-incision-plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (IMF), and the vertical axis of the breast, beneath the IMF. The upper-edge of the (future) nipple-areola complex (NAC) is marked slightly below the IMF-level, and a semicircle of 16-cm maximum diameter. In relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. The circumference of the (future) nipple-areola complex is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future NAC circumference; the incision-plan delineation continues down as a cone, and around the marked circumference.
The patient is laid supine upon the operating table so that the surgeon can later raise her to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. Afterwards, the pedicle epidermis surrounding the NAC (nipple-areola complex) is cut, and adipose tissue is liposuctioned from the breast. The medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. Then, the nipple-areola complex is transposed higher upon the breast hemisphere. The pillars of parenchymal tissue are approximated (joined), and the skin envelope is sutured. There is no evidence to support using drains during breast reduction surgery.
The woman is instructed to resume her normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassière; the convalescence regimen is for 3-months post-operative. She is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within 1-6 months post-operative; yet some cases might require surgical revision of the vertical scar. Scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications.
The post-operative complications occurred included seroma, wound dehiscence, hematoma; whereas partial NAC necrosis occurred in 10 per cent of the reduced breasts; yet, after refinement of the Lejour technique, the study Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases (1999), reported a reduced incidence rate of 7.0 per cent in the 324 breast reductions performed in 167 patients. Moreover, the incidence of such post-operative complications is greater among the women whose breasts required large-volume resection of the parenchyma; in women who were obese; in women who were tobacco smokers; and in young women. Furthermore, wound dehiscence, epidermolysis, adipose tissue necrosis, and infection occur less among women who undergo Lejour-technique breast reduction, than among women who undergo a periareolar, Anchor pattern breast-reduction, or an inferior-pedicle breast reduction. Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 per cent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 per cent of the women; and total NAC insensitivity occurs in 1.0 per cent of women.
The reliability of the lipectomy procedure was confirmed in two studies. The first, Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction (2000) reported that tumescent liposuction is a reliable reduction mammoplasty procedure, which yields consistent results of size, appearance, and texture of the reduced-volume breasts. The second study by Daniel Lanzer, Breast Reduction with Liposuction (2002), about a 250-woman cohort, reported that the application of tumescent liposuction, as the sole reduction-mammoplasty procedure, yielded consistent results wherein none of the patients had loose breast-skin envelopes, irregular breast-shape, permanent loss of sensation (either glandular, dermal, or of the NAC), scars, tissue necrosis, or infection.
After fat cells are suctioned away via liposuction, it was quoted in the Obesity journal that overall body fat generally returned to the same level as before treatment. This is despite maintaining the previous diet and exercise regimen. While the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. Visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack.
The reduction of oversized breasts by liposuction only (lipectomy) is indicated when a minor-to-moderate volume-reduction is required, and there is no breast ptosis to correct. However, in a 2001 study of 250 patients, nipple and breast elevation of between 3 cm and 15 cm was reported. Further indications for lipectomy are presented by: (i) the woman who requires a large-volume reduction, and wants un-scarred, sensate breasts, yet will accept a degree of ptosis; (ii) the woman who requires a secondary mammoplasty to correct an asymmetric breast, by up to one (1) brassière cup-size; and (iii) the girl afflicted with virginal breast hypertrophy, as a temporary procedure performed before the conclusion of her thelarche (the pubertal breast-growth phase), given the hypertrophy's high rate of recurrence.
Breast reduction by liposuction only cannot be performed upon a woman whose mammogram indicates that the oversized breast is principally composed of hypertrophied milk glands. Furthermore, liposuction mammoplasty also is contraindicated for any woman whose mammograms indicate the presence of unevaluated neoplasms; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope.
Consultation -- The plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The woman is informed of the alternative, surgical reduction techniques available for diminishing her oversized breasts; of the consequent surgical scars; of the possible loss of breast sensation; of the possible impairment of lactation capability; and of the possible impairment of breast-feeding functions. The woman is further informed of the possible medical complications, and is shown surgical photographic records of the average outcomes of breast-reduction surgery. The surgeon answers the woman's questions to assist her in establishing realistic expectations (self-image) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the volume of her breasts, a secondary, surgical breast-reduction procedure can be performed later.
The measures of the bust -- A liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the woman's breasts, chest, and torso. Yet the measures of the bust are established in order to determine the required degree(s) of correction; thus, with the patient sitting erect, for each breast, the surgeon records the jugular-notch-to-nipple distances, the nipple-to-inframammary-fold distances, and any asymmetries. Afterwards, the anaesthetized patient is laid supine upon the operating table, with her arms laterally extended (abducted) in order to fully expose the breasts.
Anaesthestic preparation -- To limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast's circulatory system is established with an anaesthetic solution (lidocaine + epinephrine in saline solution) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforation cannula, the anaesthetic infiltration begins at the deep plane of the breast, and continues as the cannula is withdrawn towards the superficial plane of the breast. The entire area of the breast is infiltrated with the anaesthetic solution until the tissues become tumescent (firm). Moreover, as required by the patient's physique, an intravenous (IV) pressure bag can be applied to hasten the infiltration; after the anaesthetic has numbed the breast, the plastic surgeon begins the lipectomy breast-reduction.
The surgeon effects a stab incision just above the lateral aspect of the inframammary fold (IMF), piercing the skin 2-cm above the inframammary fold, in the midline. The pre-tunnelling is performed with the blunt-tip, multi-perforation cannula used to infiltrate the anaesthetic solution to the breast tissues. A blunt-tip, 4-mm cannula, connected either to a medical-grade vacuum pump or to a syringe, is used to aspirate the adipose fat. The cannula is maneuvered laterally (in fanning movements), beginning in the deep plane of the breast and concluding in the superficial plane of the breast; the adipose fat sucked from the breast is a yellow, fatty, bloodless fluid; the liposuction concludes upon drawing the required volume of fat, or when the fat becomes bloody.
After the liposuction, the superficial layer of adipose fat is undermined with a blunt-tip, 3-mm cannula (which is not connected to a vacuum pump). The breast ptosis is corrected by stimulating the controlled retraction of the incision scar, by undermining the superficial fat of the medial and the lateral upper areas of the breast; the maneuver tightens (retracts) the skin envelope of the breast. Procedurally, the liposuction-only breast reduction procedure concludes with the application of an elastic, foam-tape dressing that molds the reduced breast into its new shape, and lifts it higher upon the chest.
Technical note: For the reduction of very enlarged breasts, the plastic surgeon makes a supplementary incision just above the medial aspect of the inframammary fold. Procedurally, the placement of said incision later allows converting the lipectomy breast-reduction procedure into an inferior-pedicle breast reduction surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts.
The patient is discharged from hospital either the same day or the day after the breast reduction operation. Because the liposuction-only procedure featured only a few, small, surgical incisions, the woman quickly recovers her health, usually resuming daily life activities at 14 to 28 days post-operative -- when the breast-molding dressings are changed; she also resumes her personal hygiene regimen to include washing under a water shower. In the initial convalescence period, the surgical-incision wounds are inspected at 1-week post-operative, during which time the woman has continuously worn a strapless brassière to contain and immobilize her corrected breasts; afterwards, she continuously wears a strapped brassière for 30 days after the breast-reduction operation.
Early complications include infection and hematoma (blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require either surgical or liposuction revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although the edema usually subsides at 2-3 weeks post-operative. To date, no incidence of tissue necrosis has been reported; likewise, there have been few reports of lessened nipple-sensation. Generally, the long-term rate of patient-satisfaction is high, provided that the indications for the liposuction-only technique are abided with proper patient selection.