Avoiding Complications in Breast Reduction

SUMMARY

One of the commonest cosmetic surgery operations performed by a  Plastic Surgeon  is breast reduction . Nevertheless at a training level, this is attended by complications, some of which can be severe. Also time taken in carrying out surgery is also an important factor. Perfection in achieving results is primarily to do with assessment of the breast and fitting the rightful technique for the particular breast rather than using standardised techniques in all breasts.

The main problems of breast reduction are T-junction problems, partial or total nipple necrosis, dog-ears at visible sites, fat necrosis, loss of nipple sensation, cosmetically unacceptable box-type breast.

The author here describes his own method of avoiding these problems and gives his insight as how the shape of the breast may be perfected in operation table.

INTRODUCTION

The concept of beauty has changed over ages and with culture. And with change of the aspirations towards better aesthetics,  fashions of performing breast surgery has changed. Today reduction of breast no longer involves volumetric reduction, it involves better shape with minimal complications. Everyone can perform this simple surgery. But getting it to perfection and satisfaction of the patient needs, careful review of the techniques. Complications and morbidity should be minimised as far as possible by scientific planning as per principles of Plastic Surgery.

As breast is a cone, to give it its natural shape closure must involve a three dimensional parameter. The standard wise pattern is still the golden pattern on whose structure most of the operations of breast reduction are planned.

Pre-marking the breast on a standard  wise pattern marking is totally unacceptable as there is lot of guesswork involved. And when a breast is pre-marked to a standard pattern, the surgeon is trying in table to fit the breast to these pattern markings rather than trying to design a pattern to the shape and volume of the desired breast. That is where the first trigger of an unsatisfactory result starts.

Lot has been written about this operation, pointing to the fact that everyday we are aiming at more perfection with minimum morbidity.

The other fact which has recently been accepted is that breast volume and skin reduction are two different issues which should be addressed separately. The fact that we have yet not universally accepted is the drop of a natural breast varies with age. The breast of a 19 year old and 55 year old are normally cosmetically different. When performing breast reduction this phenomenon must be taken into account as we all know that it is the lower dermal envelope which gives it its natural droop.

So premarking on a standard pattern will not address this issue. Rather this issue can be addressed only when the appropriate reduction is carried out. The surgeon can then re-assess as how this drop should be and modify the skin envelope to its desired aesthetic shape.

Complications are more common in breast reduction when the pre-marking does not tally with the assumed goal. As the young surgeon who has assessed this wrongly, desperately tries to fit the breast to his premarked shape, he compromises on the aesthetics or lands up with problems  which could have been avoided.

In this article the author uses his own modifications to overcome these problems and give an aesthetically pleasing breast. The technique described  overcomes these problems and brings breast reduction results more under the control of the surgeon.

MARKINGS

The position of the nipple areolar complex is ascertained either by bi-manually palpating the breast or  marking in the standard 19-21 cm sternal-notch and mid-clavicular distance to the centre of the nipple areolar complex. The position of the nipple is marked. A 7cm  diameter with 3.5cm on either sides of the nipple point is marked as two points freehand. From the nipple point a third point is marked 3.5cm above the nipple point of mid-clavicular nipple areolar complex axis. This point marks the superior position of nipple areolar complex. A freehand drawing is done to join these three points thus marking out the nipple areolar complex.  From the lower two points a slight curvature inwards of about 1.5cm on each side completes the nipple areolar complex marking. Two vertical parallel lines are drawn inferiorly from these points for a distance of  5cm.

Standard infra-mammary fold is marked keeping the line short underneath the breast. Sometimes this line can be drawn as a convex with convexity pointing downwards to give a better shape. Never should the infra-mammary line cross the breadth of the base of the breast, otherwise the scars will show up and look ugly.

The lowest point of vertical parallel lines is joined to the outer points of the infra-mammary line to complete the marking. The lines for the marking of superior pedicle is drawn as usual.

OPERATIVE TECHNIQUE

Prior liposuction is carried at lateral axillary folds and medial breast.

In the operating table superior pedicle is de-epithelised as usual  after tattooing the salient points. Reduction of the breast is then performed as an inferior ellipse. The remaining breast tissue is lifted off the pectoral fascia as far as the clavicle. Now incisions are made on the breast tissue enroaching on the inferior nipple areolar complex margin  keeping at least 6cm breadth of the superior pedicle. This results in the three flaps - i.e. the lateral and medial flaps and the superior pedicle.  The superior pedicle is then thinned  posteriorly  as a V to the superior pole. The amount of thinning depends on the distance of movement of the nipple areolar complex to avoid undue tension on the pedicle.  Now assessment of the desired volume is done. I usually use half strength hydrogen peroxide  soaked in a mop to decrease capillary ooze and buzz the bleeders. 

Once the volume of breast tissue is ascertained and acceptable- the tidying of the skin envelope begins. By this time there is usually an excess of skin envelope. The nipple areolar complex is stitched to its new position, including the inferior points of the nipple areolar complex  margin.  Stitching usually begins from both extreme lateral and medial ends of the inframammary line. The excess skin at the centre is excised so that the T-junction is not under tension. At the same time care is taken that the vertical inframammary suture line does not exceed 5cm as it is the dermal support for the breast which is bound to sink by the  force of gravity.

I usually use drains and close the breast in two layers - subdermal 3/0 Vikyl and subcutaneous 3/0 undyed PDS. The nipple areolar complex is closed with 4/0 Vikryl and 5/0 Ethilon. I used to use subcuticular stitches to nipple areolar complex. But as it causes constriction of the nipple areolar complex, now  I Dressing is affected by sterisrips, gauze and 4 inch elastoplast. Drains are removed at 48 hours and patient allowed home.

CLINICAL EVALUATION

The clinical evaluation of the operation was done on 100 cases performed by this method. All cases were done by author himself in a span of 3 years.

RESULTS

Indication

Number

Percentage

Different sizes

12

12%

Very large/restricting

48

48%

Self confidence/self conscious

16

16%

Painful shoulders/neck/bad back

12

12%

Cosmetic Clothing

6

6%

Breast Pain

6

6%

Breasts:

The results were based on 100 patients studied:

Table 2: Assessment of  Results of Breast Reduction

 

Nature of assessment

By Author

Mean Percentage

BREASTS

Size

Equal

Large

Average

Small

 

92

4

3

1

 

92%

4%

3%

1%

 

Shape

Good

Moderate

Bad

 

86

12

2

 

 

86%

12%

2%

 

Drop

More

Normal

Less

 

7

91

2

 

7%

91%

2%

 

Scar

Acceptable

Unacceptable

 

96

4

 

96%

4%

NIPPLE

Position of Nipple

Normal

Eccentric

 

98

2

 

98%

2%

 

 

Aesthetics of Nipple

Satisfactory

Unsatisfactory

 

 

94

6

 

 

94%

6%

 

Redundant Skin

 

3

3%

 

Protuberant Fat

 

8

8%

 

Need for Secondary Surgery

 

11

11%

 

Overall Satisfaction

Very satisfactory

Satisfactory

Acceptable

Unacceptable

71

21

6

2

71%

21%

6%

2%

 

           

STATISTICS

Table 3: Age Groups of Patients

<20

44

20-30

24

30-40

22

40-50

6

>50

4

 

Table 4: Overall Statistics

 

 

Range

Mean

Age

17-56

24

Weight of the breasts removed

150-2100

650

Bra

44GG-38C

38DD

Nipple sternal notch distance

24-37

29

Length of inframammary scar

5-10

6.5

 

COMPLICATIONS & SECONDARY SURGERY

Table 5: Types of Complications

Problem

Number

Percentage

Wound Breakdown

1

1%

Redundant Skin

3

3%

Excess Fat

8

8%

Unequal Height of Nipples

2

2%

 

Table 6: Secondary Surgery

Complications

Minor

Major

Revisions

11

0

 

Table 7: Types of Secondary Surgery

 

Problem

Number

Percentage

Nipple Correction

2

2%

Dog Ear Correction

3

3%

Secondary Liposuction

8

8%

 

 

DISCUSSION

‘To err is human’. However to err and not realise the cause of mistakes is no longer ‘human’ in the 20th century. Breast Reduction is one of the commonest cosmetic surgery performed in our everyday clinical practice. Several techniques evolve, each with its drawbacks and merits. Some leave eternal marks, others wither away to oblivion, as ‘mentioned to be discarded’. But each publication takes us a step forward in understanding of the process better.

The author describes his own modification on 100 cases of breast reduction. The results show less complications, by manoeuvring certain techniques. Of 100 cases, 86 cases achieved problem free results. There was one case of wound breakdown. This lady was 54 years old, grossly obese and in spite of being advised against surgery insisted on the operation. The 3 cases of dog ears resulted from slight over-reduction and author’s reluctance to extend the scars in young girls, hoping that elasticity of the skin will help to solve the problem. Of the 8 cases of excess fat, five were bulges in axillary region and three were in relation to dog ears. Liposuction was less then adequate in 2 cases. In the rest three the generalised obesity left unwanted bulges in the axilla.

The generalised build of the patient is very important to achieve a proper aesthetic contour. With age the drop of the breast changes. So the nipple-areolar complex distance is to be ascertained based on the age. The greater the age, the lower the nipple-areolar complex distance.

The amount of middle skin excised, in other words the pull of both the flaps to the T-junction is balanced against the possibility of T-junction problems. This is where the dynamic compromise occurs between the shape of the breast and possibilities of wound breakdown. Each case has to be weighed on its own merits. Especially where the cup size is bigger at final result , the compromise is less tolerated. And this risk becomes more apparent in young girls wanting big breasts, where elevation of the beast mound becomes important.

Curving the horizontal scar along breast curvature rather than following the transverse disposition, gives better scars hidden away from view. Above all the horizontal is made to be short, made to lie hidden under the infra-mammary fold.  Adjustment is done with vertical scar and t-junction. If a massive reduction is aimed for, primary liposuction always helps, and sometimes author warns the patient for the need of secondary surgery in order to minimise scars.

The question whether a irregular margin at nipple-areolar complex is more natural than a beautiful circle has puzzled the author for sometime. In those situation where patient feels that way the diameter of the nipple-areolar hole is made bigger following the footsteps of Marchac or  like Carlos’ peri-areolar mastopexy.

Breast reduction is an art. With all respects to wise pattern which forms the infrastructure of all breast reductions, modifications have to be made respecting patient expectations and  the individual breast, in relation to the patient’s age. No technique is perfect. The author does not claim his technique to be the be-all and end-all of breast reduction. The author has only tried to highlight the modifications which can result in a more aesthetic breast with less complications.

REFERENCES

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  2. Georgiade NG, Serafin D,Reikohl E, Georgiade GS.Is there a reduction mammoplasty for "All seasons?" Plast Reconstr Surg 1979;63:765-73
  3. 3.Mckissock PK. reduction mammoplasty with a vertical dermal flap.Plastic and Reconstructive Surgery 1972;49:245-52
  4. 4.Pitanguy I.Surgical treatment of breast hypertrophy.Br J Plast Surg 1967;20:78-85
  5. Skoog T.A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle.Act Chir Scand 1963;126:453-65
  6. Strombeck JO.Mammaplasty: report of new technique based on the two pedicle procedure.Br J Plast Surg 1960;13:79-90
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  8. Lejour M. Vertical Reduction Mammoplasty and Liposuction (Book and Video)
  9. Lejour-M :Vertical mammaplasty and liposuction of the breast.  Plast-Reconstr-Surg. 1994 Jul; 94(1): 100-14
  10. Lejour-M; Abboud-M; Declety-A; Kertesz-P. [Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar] . Ann-Chir-Plast-Esthet. 1990; 35(5): 369-79

 

 
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