| Breast reduction | |
|---|---|
 Breast reduction: the correction of macromastia and severe breast ptosis; pre-operative aspects (left); post-operative aspects (right). | |
| ICD-9-CM | 85.3 |
| MedlinePlus | 007405 |
Reduction mammoplasty (alsobreast reduction andreduction mammaplasty) is theplastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functionalbust that is proportionate to the patient's body, the critical corrective consideration is thetissue viability of thenipple–areola complex (NAC), to ensure the functional sensitivity andlactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical,aesthetic, and psychological – the restoration of the bust, of the patient'sself-image, and of the patient'smental health.[1]
In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied tomastopexy (breast lift).[2][3]
The patient withmacromastia presents heavy, enlarged breasts that sag and cause chronic pains to the head, neck, shoulders, and back; an oversizedbust also causes secondary health problems, such as poorblood circulation, impairedbreathing (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 patient affected bygigantomastia (>1,000 gm overweight per breast), the average breast-volume reduction diminished the oversized bust by three brassière cup-sizes.[4] The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations imposed by a bodily disproportionate bust; thereby, it improves a patient's physical andmental health.[5][6][7][8][9] Afterwards, the patient's ability to comfortably perform physical activities previously impeded by oversized breasts improves emotional health (self-esteem) by reducinganxiety and lesseningpsychological depression.[10]
The medical history records the patient's age, the number of children the patient has borne, the patient'sbreast-feeding practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information are the patient's history oftobacco smoking and concomitant diseases, breast-surgery and breast-disease histories, family history ofbreast cancer, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness.[citation needed]
The physical examination records and establishes the accurate measures of the patient'sbody mass index, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree ofbreast ptosis, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in thenipple–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 thethoracic region of thespinal column), skin irritation, and skin rash affecting the breast crease (IMF).[11]
Large breasts are usually developed duringthelarche (the pubertal breast-development stage), but they can also develop postpartum, after gaining weight, atmenopause, and at any age. Macromastia usually develops in consequence to thehypertrophy (overdevelopment) ofadipose fat, rather than to milk-gland hypertrophy. Moreover, many aregenetically predisposed to developing large breasts, the size and weight of which are often increased, either bypregnancy, by weight gain, or by both conditions; there also existiatrogenic (physician-caused) conditions such as post–mastectomy and post–lumpectomy asymmetry. Nonetheless, it is statistically rare for a young person to experience virginal mammary hypertrophy that results in massive, oversized breasts, and recurrentbreast hypertrophy.[citation needed]
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 themilk glands or of theadipose 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).[12]
Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy, but a weight-reduction regimen for the certain patients can alleviate some of the excessive size and volume of abnormally enlarged breasts.[13] Physical therapy provides some relief for 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.[citation needed]
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; 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 NAC, where the dark-to-light skin-color transition hides the surgical scar.[14]
Areduction mammoplasty to re-size enlarged breasts and to correctbreast ptosis resects (cuts and removes) excess tissues (glandular,adipose,skin), overstretchedsuspensory ligaments, and transposes the NAC higher upon the breast hemisphere. Duringpuberty, the breast grows in consequence to the influences of thehormonesestrogen andprogesterone; as amammary gland, the breast is composed of lobules of glandular tissue, each of which is drained by alactiferous 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 duringpregnancy andlactation, whenbreast milk constitutes most of the breast volume.[12]
Surgically, the breast is anapocrine gland overlaying the chest – attached at the nipple and suspended with ligaments from the chest – which is integral to the skin, thebody integument of the individual. The dimensions and weight of the breasts vary with 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.[15][16][17] Anatomically, thebreast topography and the hemispheric locale of the NAC are particular to each individual; 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).
Thearterial blood supply of the breast has medial and lateral vascular components; it is supplied with blood by theinternal mammary artery (from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7thintercostal perforating arteries. Drainage ofvenous blood from the breast is by the superficial vein system under thedermis, and by the deep vein system parallel to the artery system. The primarylymph drainage system is the retromammary lymph plexus in thepectoral fascia. Sensation in the breast is established by theperipheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostalnerves, andthoracic spinal nerve 4 (T4 nerve) innervates and supplies sensation to the NAC.[18][19]
In realizing the breast-reduction corrections, the plastic surgeon takesanatomic andhistologic account of thebiomechanical, 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 patient affected withmacromastia (>500 gm[clarification needed] increase per breast) or withgigantomastia (>1,000 gm increase per breast). Breast reduction surgery has two technical aspects:(i) theskin-incision pattern and theskin- and glandular-tissue excision technique applied for access to and removal of breastparenchyma 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 ofnerves and blood vessels (arterial andvenous) that ensure itstissue viability.[11]
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 patients may experience painful breast-enlargement during the first post-operativemenstruation.
Breast reduction surgery cannot be performed if the patient islactating, or has recently ceased lactating; if the patient's breasts contain unevaluatedtissue masses, or unidentified microcalcifications; if the patient has asystemic illness; if the patient is unable to understand the technical limitations of the plastic surgery; or, if the patient cannot accept the possiblemedical 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.[21]
Theinferior pedicle (central mound) features a blood vessel supply (arterial and venous) for the NAC from an inferior, centrally-based attachment to the chest wall.[22] The skin pedicle maintains theinnervation andvascular viability of the NAC, which produces a reduced, sensitive breast with fulllactational capability and function.[23] The volume and size reduction ofhypertrophied breasts is performed with a periareolar incision to the NAC, 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 NAC is transposed higher upon the breast hemisphere; thereby, the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the patients's person. Breast-reduction with an inferior pedicle occasionally produces breasts that appear squared; despite this, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia.[citation needed]
The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incisionscars and a NAC elevated by means of a pedicle (superior, medial, lateral) that maintains thebiologic andfunctional 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.[citation needed]
The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a 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 patient 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.[citation needed]
The breast reduction performed with the free nipple-graft technique transposes the NAC as atissuegraft 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 NAC, and withoutlactational capability. The medically indicated candidates are: the patient whose health presents a high risk ofischemia (localizedtissueanemia) of theNAC, which can causetissue necrosis; thediabetic patient; the patient who is atobacco smoker; the patient whose oversized breasts have an approximate NAC-to-IMF measure of 20 cm; and the patient who has macromastia, requiring much resecting of the breast tissues.[citation needed]
The breast reduction performed with theliposuction-only technique usually applies to the patient whose oversized breasts require the removal of a medium volume of internal tissue, and to the patient whose health precludes the extendedanaesthesia typical of surgical breast-reduction operations. The ideal lipectomy candidate is the patient whose low-density breasts are principally composed ofadipose tissue, have a relatively elastic skin envelope, and manifest mildptosis. 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.[12]
Themedical 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 patient 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 reductionscars; possible changes in the sensation of theNAC; possible changes inbreast-feeding capability; and possiblemedical complications. The patient also is instructed about post-operative matters, such as convalescence, and the proper care of the surgical wounds to the breasts.[citation needed]
Incision-plan delineation: to the breasts of the standing patient, the plastic surgeon delineates themosque 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) 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) NAC 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.[citation needed]
The patient is laid supine upon the operating table so that the surgeon can later raise them 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 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 NAC is transposed higher upon the breast hemisphere. The pillars ofparenchymal tissue are approximated (joined), and the skin envelope is sutured.[24][25][26] There is no evidence to support using drains during breast reduction surgery.[21]
The patient is instructed to resume 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 three-months post-operative. The patient is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within one–six months post-operative, but some cases may 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.[citation needed]
Limited evidence shows no significant benefit in the use of wound drains after reduction mammoplasty.[28]
The post-operative complications occurred includeseroma,wound dehiscence,hematoma; partial NACnecrosis occurred in 10 per cent of the reduced breasts, but, after refinement of the Lejour technique, the studyVertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases (1999) reported a reduced incidence rate of 7.0 percent in the 324 breast reductions performed in 167 patients.[29] Moreover, the incidence of such post-operative complications is greater among the patients whose breasts required large-volume resection of theparenchyma; in patients who wereobese; in patients who weretobacco smokers; and in young patients.[30][31] Furthermore, wound dehiscence, epidermolysis,adipose tissue necrosis, andinfection occur less among patients who undergo Lejour-technique breast reduction than among patients who undergo a periareolar, anchor pattern breast-reduction, or an inferior-pedicle breast reduction, however complication rates are significantly higher rate when the body mass index is greater than 30 kg/m.[32] Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 percent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 percent of patients, and total NAC insensitivity occurs in 1.0 per cent of women.[33]
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The reliability of the lipectomy procedure was confirmed in two studies. The first,Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction (2000), reported that tumescentliposuction is a reliable reduction mammoplasty procedure, which yields consistent results of size, appearance, and texture of the reduced-volume breasts.[34][35] The second study by Daniel Lanzer,Breast Reduction with Liposuction (2002), about a 250-patient 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, tissuenecrosis, or infection.[36]
After fat cells are suctioned away vialiposuction, it was quoted in theObesity journal that overallbody fat generally returned to the same level as before treatment,[37] 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.[37]
The reduction of oversized breasts by liposuction only (lipectomy) is indicated when a minor-to-moderate volume-reduction is required, and there is nobreast ptosis to correct. However, in a 2001 study of 250 patients, nipple and breast elevation of between 3 cm and 15 cm was reported.[36] Further indications for lipectomy are presented by: (i) the patient who requires a large-volume reduction, and wants un-scarred, sensate breasts, but will accept a degree of ptosis; (ii) the patient who requires a secondary mammoplasty to correct an asymmetric breast, by up to one brassière cup-size; and (iii) the patient affected byvirginal breast hypertrophy, as a temporary procedure performed before the conclusion ofthelarche (the pubertal breast-growth phase), given the hypertrophy's high rate of recurrence.[citation needed]
Breast reduction by liposuction only cannot be performed upon a patient whosemammogram indicates that the oversized breast is principally composed of hypertrophiedmilk glands. Furthermore, liposuction mammoplasty also is contraindicated for any patient whose mammograms indicate the presence of unevaluatedneoplasms; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope.[12]
Consultation: the plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The patient is informed of the alternative,surgical reduction techniques available for diminishing oversized breasts; of the consequent surgicalscars; of the possible loss of breast sensation; of the possible impairment oflactation capability; and of the possible impairment ofbreast-feeding functions. The patient 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 patient's questions to assist in establishing realistic expectations (self-image) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the breast volume, a secondary, surgical breast-reduction procedure can be performed later.[citation needed]
The measures of the bust: a liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the patient's breasts, chest, and torso, but 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, theanaesthetized patient is laid supine upon the operating table, arms laterally extended (abducted), in order to fully expose the breasts.[citation needed]
Anaesthestic preparation: to limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast's circulatory system is established with ananaesthetic solution (lidocaine +epinephrine insaline solution) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforationcannula, 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.[citation needed]
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 theanaesthetic 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 theadipose 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; theadipose 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.[citation needed]
After the liposuction, the superficial layer ofadipose 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.[citation needed]
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 this incision later allows converting the lipectomy breast-reduction procedure into aninferior-pedicle breast reduction surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts.[12]
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 patient quickly recovers their health, usually resuming daily life activities at 14 to 28 days post-operative – when the breast-molding dressings are changed; the patient also resumes their 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 patient has continuously worn a strapless brassière to contain and immobilize the corrected breasts; afterwards, the patient continuously wears a strapped brassière for 30 days after the breast-reduction operation.[citation needed]
Early complications includeinfection andhematoma (blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require eithersurgical orliposuction revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although theedema usually subsides at 2–3 weeks post-operative. To date, no incidence oftissuenecrosis 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.[13][38]
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