Choosing a technique in breast reduction

Abstract

The perfect procedure to reduce the breast has been sought for centuries. Kraske [1], modifying the technique of Lexer [2], suggested an inverted Thpattern consisting of an inferior vertical wedge glandular excision and a vertical and transverse ellipse of skin. However, lack of understanding of the blood supply to the nipple- areola complex (NAC) led to erratic results, and there was a time when a two-stage procedure was advocated. Schwarzmann, in 1930 [3], advanced the concept of a dermal pedicle using a superior and medial dermal cutaneous pedicle bridge to the NAC. This improved the safety of the procedure. The search for a reproducible design led Wise [4] to modify the pattern of Nedhoff, which led to the keyhole markings. Wise used a full thickness graffor the NAC. The inferior pedicle with the keyhole or inverted T pattern was popularized by Courtiss and Goldwyn [5], Robbins [6], and others, and is reported to be the most commonly performed technique used in the USA. In 1970, Lassus [7] described a short scar vertical mammoplasty, but it was Lejour [8] who popularized the technique. Hall-Findlay [9] subsequently simplified this technique. Most techniques of breast reduction now employ a pedicle. This improves the results with respect to nipple sensation and increases the likelihood of breast feeding aft er reduction mammoplasty. Additionally, the irregular pigmentation aft er free nipple graft ing is avoided. The blood supply to the NAC arises from four major sources. The medial pedicle arises mainly from the perforators from internal mammary vessels. The inferior pedicle is supplied by the lateral row of intercostal perforators. There is also supply from the thoraco-acromial axis superiorly and laterally from the lateral thoracic vessels. Th eoretically, there are two factors to consider when reducing the breast: first, where is the tissue excess and how is reduction to be achieved? Concomitantly, the aesthetics of the breast needs to be addressed. In any real degree of macromastia, the excess tissue exists is in the inferior pole of the breast in both horizontal and vertical planes, and thus resection of the tissue in both these planes is required. Another important factor to consider is breast aesthetics, especially the position of the nipple with respect to the rest of the breast and its relationship to the inframammary fold. While a number of articles have examined the "perfect breast," these criteria usually apply to young women with an ideal chest shape and good skin elasticity. In macromastia, the aim is to create a slightly pendulous breast rather than the breast of a nulliparous teenager. The aesthetic proportion is also age dependant and the new nipple position should be marked lower in the post partum patient, for example. A reasonable ratio of suprasternal notch to the nipple distance vs. nipple to inframammary fold distance is 3:1 or even 4:1 The keyhole/inverted T has usually (rigidly) marked the vertical limb at 5 cm, irrespective of the new nipple position! This distance is oft en too short - it stretches out with time anyway and pseudoptosis is not an uncommon sequel. In contrast, in the vertical mammoplasty no horizontal skin excision is undertaken, and the distance from nipple to inframammary fold maybe disproportionately long. Consider some commonly used techniques: 1. Keyhole/Inverted T, Inferior Pedicle: This technique was popularized in the 1970s and is based on clinical studies of its efficacy. The technique can be considered as an excision of two ellipses at 90 degrees to each other. This tissue excess is excised from the vertical and horizontal planes. This explains the versatility of the technique and explains why it is particularly useful in large reductions. The blood supply to the NAC is retained on a wide pedicle, which is reported to be safe at a length of 20-25 cm. While the inferior pedicle is reliable, it suff ers from a number of "mechanical" disadvantages. First, the inferior pedicle is inferior and thus the excess tissue that is inferiorly situated cannot all be excised. More importantly, as the inferior pedicle lies under the point of maximum tension of the adjacent skin flaps, breakdown at the T is not uncommon. In fact, the more bulk in the pedicle, the more tension is applied to the T junction, with subsequent skin (and fat) necrosis. However, this is a versatile, safe technique, which explains its popularity. 2. Inverted T/Keyhole with Superior-Medial Pedicle: The superior medial pedicle has a number of advantages. It permits the excess tissue situated inferiorily to be excised without impedance. Additionally, the pedicle is rotated from an inferior position to a superior position, and theoretically at least, tissue is redistributed into a more appropriate location. However, whether these theoretical benefits translate into a better long-term result remain unproven. Perhaps a lesser known fact about the superior medial pedicle is the robustness of its blood supply. Anatomical studies by Palmer and Taylor [10] demonstrated that the dominant blood supply to the NAC is medial, and a recent study attests to its reliability in gigantomastia. 3. Vertical Mammaplasty (VM): The technique (or its variations) has gained in popularity in recent years. While similar techniques were described in the 1950s, Lejour [8] championed its resurgence. The original technique described by Lejour was associated with an unacceptable complication rate. Hall-Findlay modified and simplified the technique and also improved its safety. The VM has a number of fundamental differences to the keyhole pattern: A more limited skin incision - only a vertical ellipse of skin is excised, although parenchymal tissue is excised in both a vertical and inferior horizontal plane. Parenchyma sutures are inserted. The two breast pillars that are created are sutured together, the so-called "parenchymal moulding. " This is said to "cone" the breast and increase projection. A superior or superior-medial pedicle is used. Commonly (but not always) the original inframammary fold is destroyed, and a new fold is created superior to the original fold. The vertical scar should preferably not extend below the new inframammary fold, so the fold cannot be raised very much. 4. Periareolar Reduction mammaplasty: This technique, except perhaps in South America, has not gained widespread popularity. It has a limited skin resection and this technique is only really applicable to lesser degrees of breast hypertrophy. Additionally, the technique truncates the apex of the breast cone, resulting in a flat, poorly projecting breast. Furthermore, as the periareolar incision is cinched and reduced to the size of the new areola, a wrinkling of the skin occurs and a star burst appearance is not uncommon. No parenchymal remodeling occurs, which led Goes [11] to insert a mesh as an internal brassiere. This brings in a new component to the procedure in addition to expense. 5. Liposuction: Liposuction relies on skin retraction to achieve its improvement in shape, which is an obvious limitation in the breast. Liposuction cannot really remove (much) breast tissue, but only successfully removes fat, but Lejour noted that it is very difficult to determine preoperatively how much of the breast is actually fat. It has obvious advantage of limited scarring. Liposuction is useful as an adjunctive maneuver in breast reduction. © 2009 Springer-Verlag Berlin Heidelberg.