Breast reduction

From Wikipedia, the free encyclopedia

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.[1]
In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are
applied to mastopexy (breast lift).[2][3] Moreover, the correction of gynecomastia ("woman's
breast") is the analogous, enlarged male breast-reduction surgical procedure, wherein there is no
consideration of lactation capability.[4]
Contents
1 The patient
1.1 Presentation
1.2 Medical history
2 Enlarged breasts
2.1 Etiology
2.2 Therapeutic approaches
2.2.1 Medical
2.2.2 Surgical
3 Surgical anatomy of the breast
3.1 The procedure
3.2 Composition
3.3 Blood supply and innervation
3.4 Mechanical structures of the breast
4 Surgical procedures
4.1 General
5 Surgical techniques
5.1 Lejour technique breast reduction
5.1.1 Pre-operative matters
5.1.2 Operative technique
5.1.3 Notes
5.1.4 Post-operative matters
5.1.5 Complications
5.2 Liposuction-only technique
5.2.1 Indications
5.2.2 Contraindications
5.2.3 Pre-operative matters
5.2.4 Operative technique
5.2.5 Post-operative matters
5.2.6 Convalescence
5.2.7 Complications
6 See also
7 References
8 External links
The patient
Presentation
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 breast surgery with air); chafing of the skin of the chest and the
lower breast (inframammary intertrigo); brassire-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) brassire cup-sizes.[5] 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.[6][7][8][9] 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.[10]
Medical history
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 brassire 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).[11]
Enlarged breasts
Breast reduction: the pre-operative (l.) and post-operative (r.) aspects of the correction of
macromastia and breast ptosis in a young woman.
Reduction mammoplasty: the degree of breast ptosis, the falling forward (prolapsation) of the breast,
determines the applicable surgery technique.
Etiology
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).[12]
Therapeutic approaches
Medical
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.[13] 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.
Surgical
Reduction mammoplasty, surgery or lipectomy, is the technically reliable method for diminishing the
size and volume of the enlarged breast. 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.[14]
Surgical anatomy of the breast
The procedure
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.[12]
Composition
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.[15][16][17] 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).
Blood supply and innervation
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.[18][19]
Surgical anatomy of the mammary gland for reduction mammoplasty correction:
1. Chest wall
2. Pectoralis muscles
3. Lobules
4. Nipple
5. Areola
6. Milk duct
7. Fatty tissue
8. Skin envelope
Mechanical structures of the breast
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).
Rib cage. The 2nd, 3rd, 4th, 5th, and 6th ribs of the thoracic cage are the structural supports for the
mammary glands.
Chest muscles. The breasts overlay the pectoralis major muscle, the pectoralis minor muscle, and
the intercostal muscles (between the ribs), and can extend to and cover a portion of the (front)
anterior serratus muscle (attached to the ribs, the rib muscles, and the shoulder blade), and to the
rectus abdominis muscle (a long, flat muscle extending up the torso, from pubic bone to rib cage).
The body posture of the woman exerts physical stresses upon the pectoralis major muscles and the
pectoralis minor muscles, which cause the weight of the breasts to induce static and dynamic shear
forces (when standing and when walking), compression forces (when lying supine), and tension
forces (when kneeling on four limbs).
Pectoralis fascia. The pectoralis major muscle is covered with a thin superficial membrane, the
pectoral fascia, which has many prolongations intercalated among its fasciculi (fascicles); at the
midline, it is attached to the front of the sternum, above it is attached to the clavicle (collar bone),
while laterally and below, it is continuous with the fascia.
Suspensory ligaments. The subcutaneous layer of adipose tissue in the breast is traversed with thin
suspensory ligaments (Cooper's ligaments) that extend obliquely to the skin surface, and from the
skin to the deep pectoral fascia. The structural stability provided by the Cooper's ligaments derives
from its closely packed bundles of collagen fibers oriented in parallel; the principal, ligament-
component cell is the fibroblast, interspersed throughout the parallel collagen-fiber bundles of the
shoulder, axilla, and thorax ligaments.
Glandular tissue. As a mammary gland, the breast comprises lobules (milk glands at each lobe-tip)
and the lactiferous ducts (milk passages), which widen to form an ampulla (sac) at the nipple.
Adipose tissue. The fat tissue of the breast is composed of lipidic fluid (60-85% weight) that is 90-99
per cent triglycerides, free fatty acids, diglycerides, cholesterol phospholipids, and minute quantities
of cholesterol esters, and monoglycerides; the other components are water (5-30% weight) and
protein (2-3% weight).
Fatty Tissue. In Biology, adipose tissue (/'d??po?s/) or body fat or fat depot or just fat is loose
connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in
its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts. Its main
role is to store energy in the form of lipids, although it also cushions and insulates the body. Far
from hormonally inert, adipose tissue has in recent years been recognized as a major endocrine
organ[1], as it produces hormones such as leptin, resistin, and the cytokine TNF?. Moreover, adipose
tissue can affect other organ systems of the body and may lead to disease. Obesity or being
overweight in humans and most animals does not depend on body weight but on the amount of body
fat--to be specific, adipose tissue. Two types of adipose tissue exist: white adipose tissue (WAT) and
brown adipose tissue (BAT). The formation of adipose tissue appears to be controlled in part by the
adipose gene. Adipose tissue was first identified by the Swiss naturalist Conrad Gessner in 1551.
The skin envelope. The breast skin is in three (3) layers: (i) the epidermis, (ii) the dermis, and (iii)
the hypodermis. The epidermis is 50-100 m thick, and is composed of a stratum corneum of flat
keratin cells, that is 10-20 m thick; it protects the underlying viable epidermis, which is
composed of keratinizing epithelial cells. The dermis is mostly collagen and elastin fibers embedded
to a viscous water and glycoprotein medium. The fibers of the upper dermis ("papillary dermis") are
thinner than the fibers of the deep dermis, thus the skin envelope is 1-3 mm thick. The thickness of
the hypodermis (adipocyte cells) varies from woman to woman, and body part.[20] The skin of the
nipple and areola is further composed of a modified and specialized myoepthelium that is
responsible for contraction in response to stimuli.
Surgical procedures
Reduction mammoplasty: The keyhole incision plan for correcting macromastia; the sagging,
hypertrophied breast (l.), the surgical reduction procedure (c.), the reduced, elevated breast (r.).
Breast reduction: foremost is the tissue viability of the nipple-areola complex (NAC); it also hides a
periareolar scar in the skin-color transition at the areolar periphery.
Reduction mammoplasty: The vertical scar technique (lollipop incision) and the inferior pedicle flap
technique (anchor incision) also are applicable to breast lift surgery.
General
Reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging
breasts of a woman afflicted either with macromastia (<500 gm 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.[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-opertaive,
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.
Contraindications
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.
I. Inferior pedicle technique (Anchor pattern, inverted-T incision, Wise pattern)
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.[21] The
skin pedicle maintains the innervation and vascular viability of the NAC, which produces a reduced,
sensitive breast with full lactational capability and function.[22] 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.
II. Vertical scar technique (lollipop incision)
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.
III. Horizontal scar technique
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.
IV. Free nipple-graft technique
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 requires much resecting of the breast tissues.
V. Liposuction-only technique (lipectomy)
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.[23]
Surgical techniques
Lejour technique breast reduction
Breast reduction: the pre-operative aspects of severe ptosis and macromastia; the post-operative
corrected breasts and the lifted bust.
The treatment of macromastia and gigantomastia with the Lejour technique applies a vertical-
incision, a superior pedicle, breast liposuction, and wide undermining of the skin of the lower
portion of the breast. The technical efficacy of the Lejour breast reduction was established with the
study Vertical Mammaplasty and Liposuction of the Breast (1994), which reported 153 reduction
mammoplasties performed in 79 patients, wherein an average fat volume of 300 ml was removed
from each breast, and the average resection of 480 gm of parenchymal tissue was removed from
each breast.[24]
Pre-operative matters
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.
Operative technique
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.[25][26][27]
Notes
Biological: The resected tissue is submitted to histopathologic examination, because sub-clinical
breast cancer foci occur in 0.1-0.9 per cent of the tissue specimens.
Technical: The original Lejour technique incision plan had no horizontal limbs, and so did not
produce horizontal scars; however, contemporary variants, such as the Modified Lejour Technique,
employ small, horizontal incisions along the inframammary fold, in order to avoid redundant skin
folds, especially in the reduction of very oversized breasts.[28]
Post-operative matters
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 brassire; 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.
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.[29] 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.[30][31] 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.[32]
Liposuction-only technique
The reliability of the lipectomy procedure was confirmed in two studies: (i) 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;[33][34] and (ii) the study 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.[35]
Indications
The reduction of oversized breasts by liposuction only (lipectomy) is indicated when a minor-t-
-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.[35]
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) brassire
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.
Contraindications
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.[36]
Reduction mammoplasty: The liposuction-only technique affords a medium-volume reduction, and
leaves small incision scars.
Pre-operative matters
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.
Operative technique
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 (suck) 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.[12]
Post-operative matters
Convalescence
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 brassire to contain and immobilize her corrected breasts;
afterwards, she continuously wears a strapped brassire for 30 days after the breast-reduction
operation.
Complications
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.[37][38]
See also
Accessory breast
Breast augmentation
Breast implant
Breast ironing
Breast reconstruction
Hypertrophy of breast (gigantomastia and macromastia)
Mastopexy
References
^ Anastasatos JM. Medial Pedicle and Mastopexy Breast Reduction (2010) emedicine.medscape.com
^ De la Torre, JI. Breast Mastopexy. (2009) eMedicine.medscape.com
^ Anastasatos, JM. (2009) Medial Pedicle and Mastopexy Breast Reduction Treatment &
Management.eMedicine.medscape.com
^ Breast Implants 411: "Helping Boys Overcome Self-Consciousness"
^ Heine N, Eisenmann-Klein M, Prantl L. Gigantomasty: Treatment with a Short Vertical Scar.
Aesthetic and Plastic Surgery. January 2008;32(1):41-47.
^ O'Blenes CA, Delbridge CL, Miller BJ, Pantelis A, Morris SF. Prospective Study of Outcomes after
Reduction Mammaplasty: Long-term Follow-up. Plastic and Reconstructive Surgery February
2006;117(2):351-358.
^ Miller BJ, Morris SF, Sigurdson LL, Bendor-Samuel RL, Brennan M, Davis G, et al. Prospective
Study of Outcomes after Reduction Mammaplasty. Plastic and Reconstructive Surgery April
2005;115(4):1025-1031; discussion 1032-1033.
^ Mello AA, Domingos NA, Miyazaki MC. Improvement in Quality of Life and Self-Esteem After
Breast Reduction Surgery. Aesthetic Plastic Surgery. 19 September 2009.
^ Cherchel A, Azzam C, De Mey A. Breastfeeding after Vertical Reduction Mammaplasty using a
Superior Pedicle. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2007;60(5):465-470.
^ Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ, Walker LG. Effects of Bilateral Breast Reduction on
Anxiety and Depression: Results of a Prospective Randomised Trial. Scandinavian Journal of Plastic
and Reconstructive Surgery and Hand Surgery. 2006;40(1):19-23.
^ a b Espinosa-de-los-Monteros A, De la Torre JE. Lejour Breast Reduction. eMedicine (30
September 2009)
^ a b c Grippaudo FR, Kennedy DC, Tiwari P, Talavera F, Shenaq SM, Slenkovich NG. Liposuction
Only Breast Reduction. (7 July 2009) eMedicine.com
^ Sadove R. New Observations in Liposuction-only Breast Reduction. Aesthetic Plastic Surgery. 9
March 2005.
^ Benelli L. A New Periareolar Mammaplasty: The "round block" Technique. Aesthetic Plastic
Surgery. Spring 1990;14(2):93-100.
^ Pamplona DC, de Abreu Alvim C. Breast Reconstruction with Expanders and Implants: a
Numerical Analysis. Artificial Organs 8 (2004), pp. 353-356.
^ Grassley JS. Breast Reduction Surgery: What every Woman Needs to Know. Lifelines 6 (2002), pp.
244-249.
^ Azar FS. A Deformable Finite Element Model of the Breast for Predicting Mechanical
Deformations under External Perturbations. (Doctoral thesis) Department of Bioengineering,
University of Pennsylvania, Philadelphia, Penn., USA, 2001.
^ Introduction to the Human Body, Fifth Edition. John Wiley & Sons, Inc.: New York, 2001. 560.
^ Ramsay DT, Kent JC, Hartmann RA, Hartmann PE (June 2005). "Anatomy of the lactating human
breast redefined with ultrasound imaging". Journal of Anatomy 206 (6): 525-534. doi:10.1111/j.1469-
7580.2005.00417.x. PMC 1571528. PMID 15960763.
^ Gefen A, Dilomeyb B. Mechanics of the Normal Woman's Breast. Technology and Health Care 15
(2007) pp. 259-271 IOS Press
^ Vertical Scar Versus Inferior Pedicle Reduction Mammoplasty. ClinicalTrials.gov
^ Kakagia D, Tripsiannis G, Tsoutsos D (2005). "Breastfeeding after Reduction Mammaplasty: a
Comparison of 3 Techniques". Annals of Plastic Surgery 55 (4): 343-345.
doi:10.1097/01.sap.0000179167.18733.97. PMID 16186694.
^ Romana Grippaudo, F. Liposuction Only Breast Reduction. eMedicine.com
^ Lejour M. Vertical Mammaplasty and Liposuction of the Breast. Plastic and Reconstructive
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^ Kakagia D, Fragia K, Grekou A, Tsoutsos D. Reduction Mammaplasty Specimens and Occult Breast
Carcinomas. European Journal of Surgical Oncology. February 2005;31(1):19-21.
^ Pitanguy I, Torres E, Salgado F, Pires Viana GA. Breast Pathology and Reduction Mammaplasty.
Plastic and Reconstructive Surgery. March 2005;115(3):729-734; discussion 735.
^ De Groot RM, Kingma-Vegter F, Bakker XR. Occult Breast Cancer Discovered following Breast
Reduction. Nederlands Tijdschrift voor Geneeskunde (Netherlands Journal of Medicine). 2009;153.
^ Azzam C, De Mey A. Vertical scar Mammaplasty in Gigantomastia: Retrospective Study of 115
patients Treated using the Modified Lejour Technique. Aesthetic Plastic Surgery. May-June
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^ Lejour M. Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases.
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^ Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of Breast Reduction Complications
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^ Schumacher HH. Breast Reduction and Smoking. Annals of Plastic Surgery. February
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^ Hofmann AK, Wuestner-Hofmann MC, Bassetto F, Scarpa C, Mazzoleni F. Breast Reduction:
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^ Klein JA. Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction. St Louis: CV
Mosby, 2000
^ Dryden RM, American Academy of Cosmetic Surgery Conference, Florida, February 2000.
^ a b Lanzer D, Breast Reduction with Liposuction. International Journal of Cosmetic breast surgery
Pittsburgh Surgery and Aesthetic Dermatology, Volume 4, Number 3, 2002.
^ Grippaudo FR, Kennedy DC, Tiwari P, Talavera F, Shenaq SM, Slenkovich NG. Liposuction only
Breast Reduction. (7 July 2009) eMedicine.com
^ Sadove R. New Observations in Liposuction-only Breast Reduction. Aesthetic Plastic Surgery. 9
March 2005
^ McMahan JD, Wolfe JA, Cromer BA, Ruberg RL. Lasting Success in Teenage Reduction
Mammaplasty. Annals of Plastic Surgery. September 1995;35(3):227-231.
External links
Breast Feeding After Reduction (BFAR)
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