Principles of breast reduction surgery

Abstract

Each form of reduction mammoplasty, depending on the vascular pedicle, has its own possible problems. Over the years some principles have evolved that may help keep the surgeon out of trouble. Principles 1. Obtain all records of earlier breast surgeries and review the surgical reports prior to performing breast reduction. a. Beware of prior breast augmentation that has utilized an inframammary incision. An inferiorbased pedicle probably cannot be used in this situation. b. In secondary breast reductions, do not cut across the prior pedicle, except if the earlier procedure was bipedicle then one pedicle can been transected. 2. Obtain a preoperative mammogram on all patients preferably, but at least those over 35-40 years of age. a. This may prevent the accidental incision into a cancer. 3. Obtain preoperative photographs on all patients. a. This will substantiate preoperative asymmetry or other deformities. 4. Always mark the breast for skin incisions and possibly glandular excisions before surgery. a. Mark in the sitting or standing position. b. Freehand artistry with a scalpel may be used with certain techniques, but is not for the novice. i. Freehand artistry is more prone to asymmetry, as it requires a large amount of experience to resect the correct amount of tissue. c. Freehand artistry requires training before attempting the technique. 5. Record the following measurements: a. Sternal notch and/or mid clavicle to nipples b. Nipples to midline c. Extent of ptosis: the degree of ptosis and/or measurement from nipple to inframammary fold and inframammary fold to lowest point of breast d. Inframammary fold to superior point of the planned areola 6. Remove only that amount of breast tissue to relieve the symptoms of enlarged breasts and to satisfy the patient as to cup size. a. Most patients do not wish to have an A cup following breast reduction from a D or larger cup size. 7. When estimating the position of the new nipple in very large breasts, lower the site of the new nipple between 1 and 2 cm from the level of the inframammary fold depending on the size of the breast. a. If the new nipple site is not lowered, the nipple- areolar complex may be too high and will show in a brassiere or bathing suit. 8. If the nipples are rotated laterally, use the distance from the midline (10-12 cm) to establish the new nipple position rather than the line from the mid clavicle or sternal notch to the nipple. 9. Pedicles a. Do not thin pedicle excessively. b. Long pedicles should be at least 6 cm in width. c. A superior pedicle over 12 cm in length may not survive [1]. d. Observe for twisting of the long pedicle at the time of closure. e. Check the nipple-areolar complex at the completion of closure for early evidence of vascular congestion or cyanosis. 10. Breast skin flaps should be undermined minimally or not at all. 11. Consider nipple areola transplant in very large breasts. a. When the excision will be over 1 kg in weight [2] or when the distance from the inframammary fold to the upper rim of the keyhole pattern exceeds 35 cm [2]. b. Place graft on a flat, deepithelialized bed, not on subcutaneous fat. c. See the patient on the first postoperative day to make sure there is no hematoma and that the nipple-areolar complex is not cyanotic. d. Venous refill of the nipple-areola complex should always be less than 6 s. If more than 6 s, the surgeon should seriously consider nipple areola transplant to prevent nipple areola necrosis. 12. Smoking should be stopped at least 2 weeks before and 2 weeks aft er surgery to prevent postoperative necrosis. © 2009 Springer-Verlag Berlin Heidelberg.