Repeat reduction mammaplasty

Abstract

The author is not addressing minor aesthetic deformities such as dog ears, unsightly scars, or breast asymmetry, but rather addresses the uncommon problem of a patient presenting and requesting further reduction of an enlarged breast after a previous reduction mammaplasty. Repeat breast reduction appears to have been an uncommonly performed procedure before the 1990s as there was almost no literature on the subject. Probably the changes in techniques of breast reduction, particularly the popularising of short scar techniques, combined with advances in breast reconstruction are partly responsible for these changes [1]. The reasons for patients seeking repeat breast reduction remains poorly defined, although logically it is either recurrence of the hypertrophy or inadequate primary excision [2]. Obviously, a reduction performed as an adolescent for virginal hypertrophy may require repeating when the person reaches adulthood. One of the problems of the short scar techniques is to under resect breast tissue at reduction, whereas other patients put on weight leading to a repetition of mammary hypertrophy. The role of pregnancy, drugs and changes in weight are unknown factors in this entity. Pseudoptosis is not an uncommon consequence of a previous breast reduction. The problem may be aggravated where the nipple is placed too high, above the inframammary fold (IMF) in the original reduction. With the passage of time and the eff ect of gravity, breast tissue descend inferiorly. This lengthens the distance from the inframammary fold to the nipple, oft en originally set at 5 cm. This excess tissue now situated in the inferior pole of the breast may result in the nipple pointing towards the ceiling and also impairs the aesthetics of the reduced breast. The key issue to consider relates to the blood supply of the nipple-areola complex (NAC). Almost all modern techniques of breast reduction employ a pedicle. Necrosis of the NAC is a feared complication in the first procedure. The risk is even greater in the second procedure. The NAC blood supply, previously rich and derived from a number of different sources, is now axial via the pedicle, although some neovascularization from the surrounding tissue also contributes. This axial supply must be retained to prevent nipple necrosis, especially if the position of the NAC is to be moved. © 2009 Springer-Verlag Berlin Heidelberg.