Breast Reduction into Next Millenium
Whenever we talk of female beauty, breast is invariably associated as one of its attributes. Why? Our first food after birth comes from the breast, raises an eternal bondage according to the Freudian philosophy.
The idea of the beauty has changed over ages, in different cultures and at various stages of civilisation, along with its individual perception. This is mainly related to facial aesthetics and body contour. Seldom much is talked about breast- except that it is ornamental in a female, as much as it is the first contact between a mother and a child after birth.
We know that the breast extends from 2nd to the 6th rib, from mid-axillary line to the sternum and it develops on the mammary line. This is as far as the anatomy is concerned. But what about the aesthetics?
Figure 1: Over-augmented Breast
Figure 2: Correctly Augmented Breast
Figure 3: Aesthetic Profile of Breast on Sketch
In recent years I have endeavoured to project the aesthetics of the female breast to the international community. Though Pamela Anderson or Dolly Parton may have an attraction(?) to the male eye, yet no artist or sculptor would attribute those breasts as the epitome of beauty. If we look at two augmented breasts, which looks normal? In Figure 1 the breasts have been over-augmented and also it shows sagging of traditional prosthesis with gravity. In Figure 2 the augmentation is balanced with the natural drop. Also it's ‘proportions to the body’ (Figure 3) of the individual ( i.e., height, structure, girth etc.) has to be considered, when visualising the outcome.
The first and foremost is a philosophy, that there is a gradual droop of the breasts with age. The breast of an eighteen year girl and that of a fifty-five year old lady is not the same. This natural droop with age forms the aesthetic basis of performing breast surgery.
Figure 4: Indian Sculpture
Figure 5: Radha
Figure 6: Bronze Figurine
On the lateral profile the line from clavicle to the nipple must be straight line, rather than an obvious convex curve. This fact is substantiated by the painting of Radha (Figure 5) or an extract from Indian sculpture (Figure 4) or from a bronze figurine (Figure 6)
Aesthetic Surgery is an art and the success of the cosmetic surgeon lies in the fact that the profile is enhanced, yet nobody can recognize that the lady underwent cosmetic surgery. This is where the natural aesthetics of the breast should be taken into account. The other factor, while performing this surgical art- is not only the immediate result, but also its long-term aesthetics. Gravitational changes with aging do play an important role together with the intrinsic changes as skin elasticity, fine epidermal lines, ultra-violet changes (if one happens to be a topless sun worshipper!) and pigmentary changes specially in a person with dark skin, also cannot be ignored.
That the fashions of performing breast reduction surgery are changing, is reflected in our human beings’ eternal quest for a change due to our inherent dissatisfaction with what is present. But it is good to remember the golden words of Euripedes (484-406 B.C.) that moderation is the noblest gift of heaven.
This forms the aesthetic framework of the art of breast surgery into the next millennium.
Figure 7: Breast Reduction - An Artistic Concept
Large breasts may be attractive to some male eye, but it causes enormous inconvenience to the victimized female. In addition to breast pain it also causes shoulder, neck and back pain. Getting the right cosmetic clothing (bra etc.) to turning from one side to the other or carrying out gymnastics, it is a nuisance to the person who develops this hypersensitivity of the oestrogen receptors during puberty. The social comments to the downward fixation of a male vision in a discourse - shatters the identity.
We all know, while performing this procedure certain basic protocols are to be always kept in mind:
- The distance of the nipple-areolar complex (NAC) is 19-21cm from mid-clavicular point and manubrium sterni.
- The medial border of NAC is 9cm from mid-sternal line
- The infra-mammary point is 11cm from the same.
- Distance from lower border of NAC to infra-mammary fold is 5cm.
This basic measurements are always to be kept in mind for anyone performing breast reduction or mastopexy.
To alleviate the problem of large breasts, though amputation of the breast may have started the reduction technique, yet it was RS Wise in 1956 who suggested the key-hole pattern of reduction.- to give it the cone shape. Breast is a cone and its reduction must be in a three-dimensional plane. The other issue was preserving the blood-supply to the nipple-areolar complex, which is supplied from all sides. In came techniques of Duformental,b-Reduction, McKissock, Pitanguy, Skoog , Strombeck, Robbins etc. and all breasts landed with a standard Wise pattern of inverted T-shaped scar.
Today’s breast reduction entails reduction of the breast and correction of skin envelope, whereas mastopexy is correction of the skin envelope only. That, in breast reduction, two different entities play a role individually and each must be addressed in its own merit brought a new dimension to the philosophy of breast reduction.
Reducing the scarring was the next phase in the agenda and Mouly aimed at an oblique scar, while Rudolf Myer aimed at an L-scar. Several others gave their own ways   to this concept. It was Daniel Marchac who proposed reducing the infra-mammary scar at the cost of compensation at nipple-areolar complex level. The ideas of Mouley and Marchac were further modified by Lassaus   into a vertical scar, which was popularised by Lejour   .
To reduce a three-dimensional structure, the philosophy is, it has to be in two planes- i.e. vertical and horizontal. The central approach through the peri-areolar route achieves both these at the same time, at the cost of circular scar contracting. The problem is maintaining the contour, when techniques are being suggested to convert this to a two dimensional plane. Horizontal reduction results in flattening of the breast. The vertical reduction of Lejour or Lassaus produces excessively long infra-mammary scar and excessive infra-mammary skin tissue resulting in sagging later on.
Several other techniques as axillary approach, Erich Lexter’s Mammoplasty attempted by Hinderer were born and pedicles were switched, sometimes keeping the vertical scar  or converting Marchac’s superior pedicle to an inferior one and in came the SPAIR technique to play its harmony in the symphony of breast reduction orchestra. Some other techniques as horizontal scar and liposuction  of the breast were tried and died even before they were born. Breast is a fibro-fatty-glandular organ - and liposuction can only remove the fatty element, but not the other two.
Figure 8: Picasso
It does matter what pedicle you choose. The choice of pedicle basically depends on the original position of the NAC and the amount of reduction you are trying to achieve. The philosophy is that the skin envelope must not compress the pedicle to interfere with the blood-supply, in most cases it happens to be the venous. If there is doubt it is advisable to go for a free nipple transfer.
Having established different techniques of breast reduction and reducing scarring, the key issue now in the next millennium is fighting against gravity. No matter whatever we try to lift up, we are trying to fight gravity, which is tending to bring the structure down. If we follow breast reduction for quite some time they all tend to sag back. This issue is the key factor in the development of new techniques in breast reduction, which is the way forward into 2000.
With the establishment of the evidence that nipple areolar complex is supported by a central posterior core of blood vessel (Levet ) and the fact that the breast is a combination of two key issues- the breast tissue itself and its skin envelope,  Savaci proposed a peri-areolar reduction which was later modified by others  . These secondary concepts were essentially an admixture of Marchac’s concept adapted to a peri-areolar route. In my experience, the problem is when there is no dermal support following peri-areolar reduction, under the influence of gravity and the lateral pillars falling apart as stitches dissolve or give way, the breast in no time loses its projection and assumes a male form. Savaci’s idea was further developed by Wuringer  to hold up the breast against gravity. Later other techniques as trap-doors under pectoralis were tried to achieve this goal. Trap dooring the pedicle in-between pectoralis is a dangerous proposition and may put the vascularity of the nipple-areolar complex unnecessarily to risk. Other methods to hold the breast up are being experimented. Though the idea of superficial fascial system (SFS)  suspension looks great, theoretically, it does not have enough strength against gravity. On the other hand Frey’s idea of using the inferior skin de-epithelised to provide a secondary dermal support looks more promising , but in breasts where reduction is minimal, getting enough length of the skin for suspension can be a problem. I would prefer to hold the breast by a secondary dermal support from below rather than pull it from above. Moreover, whatever stitch is applied to pectoral fascia or periosteum , under the influence of gravity it tends to give way. The only secure place is a wrap around with the rib and costal cartilage. Lindquivist’s bio-absorbable screws to secure this with rib may be the answer.
I remember Carlos in the International Society of Aesthetic Plastic Surgeons meet propose in presence of Levet the first concept of peri-areolar reduction on a central pedicle wrapped with a vikryl mesh, though while writing this article I could not see any publications to that effect.
Has anyone thought about a free fascial transfer?
What I have been talking to the international community about the gradual droop of breasts, holds true, no matter what technique we apply. It is to be borne in mind while correcting the skin pedicle and to achieve this modifications are to be made to the standardised measurements as I have mentioned before.
To sum the desired goal is achieving a breast size in proportion to the body, which is natural looking with minimal scars and holding for as long as we can.
Breast is an intensely personal organ of a lady - and there is a relationship of this femininity to her soul. So whenever a surgeon attempts to perform this surgery, let us remember that we are playing with her femininity - and surgery done in the wrong way, is a monstrous abuse of her femininity. Changes may come and go, fashions of performing breast surgery may change further in the next millennium, but the eternal philosophy of human psychology in relation to this organ will not change. Even before attempting to put a knife in it, one must always remember, they are delicate and must be dealt with expertise, professionalism, aesthetics and art. Beauty is what looks pleasing to the beholder and patient itself. The patterns of performing aesthetic breast surgery will re-fashion, re-model and re-vibrate around the rhythms of the present philosophy to achieve the ultimate perfection. But the truth has always to be remembered, that no technique can even go near to that of the Eternal Creator.
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