Chapter 54: Breast Reduction

Penn1 studied breast aesthetics in the 1950s. He reviewed a number of females and concluded that certain measurements provided an aesthetically pleasing breast. In Penn’s ideal breast measurements, the sternal notch- to-nipple distance was 21 cm and was equivalent to the internipple distance. The vertical nipple-to-inframammary fold (IMF) distance was 7 cm. Breast base width was not described. A normal nipple-areola complex is between 3.8 and 4.5 cm but there is significant variation beyond this. A clear understanding of normal breast aesthetics is vital for performing corrective breast surgery (Fig. 54.1). 21 cm 19-21 cm 7-8 cm 21 cm 21 cm MCP Acromion MHP INP Lateral epicondyle SN 21 cm IMF 6.9 cm Fig. 54.1 Ideal breast measurements. (IMF, Inframammary fold; INP, ideal nipple plane; MCP, midclavicular point; MHP, midhumeral plane; SN, sternal notch.) (B, From Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. St Louis: Quality Medical Publishing, 2011.)

Classic numbers associated with an aesthetic breast for nipple position are 21 cm from the sternal notch to nipple and a nipple-to-inframammary fold (IMF) distance of approximately 7cm.1 Of course, these can vary considerably between individuals based on their frame and breast shape/size. When marking up a patient for bilateral breast reduction, there are three useful guides to vertical nipple placement: the IMF, the distance from the sternal notch, and the midhumeral point when arms are placed by the patient’s side. The point at which the IMF level is transposed to the anterior breast is known as Pitanguy’s point and is a reliable guide to ideal nipple position in most patients. A range of distances (21–24 cm) from the sternal notch-to-nipple are generally applicable, but 26 cm would be too low in most cases. Many surgeons will use all three measurements/landmarks to guide their decision-making. The main aim is to ensure the nipple-areola complex (NAC) is placed at an aesthetically pleasing point on the most projected part of the breast, while ensuring it is not placed too high, otherwise this makes it visible above the bra or a low cut dress. Furthermore, it is difficult to correct without additional unwanted scarring.2

In most patients with hypermastia, there are both normal estrogen levels and receptor number, which suggests that the abnormal excessive breast growth may be the result of an altered response to normal circulating estrogens. The main increase in breast volume is observed in fibrous and fatty tissue rather than within glandular tissue.1

Juvenile virginal hypertrophy of the breast (gigantomastia) has an unknown etiology and patients usually have a normal endocrine profile. Onset occurs shortly after the girl’s first menstruation with excessive growth of both breasts. Surgical management with breast reduction is the mainstay of treatment with at least 1800 g typically removed. There is a risk of recurrence following resection and this is particularly high during pregnancy. Regression is rare without intervention.1,2

Suction lipectomy has limited indications for use as a stand-alone technique in breast reduction. It is more commonly used in conjunction with an excisional technique to shape specific areas of the breast. When used independently as a reduction technique it is best reserved for older patients with large, heavy breasts as they tend to have a higher proportion of fat within the breast that can be removed with liposuction. Suction lipectomy is less effective in younger patients as they have more parenchyma and less fatty tissue. This is particularly true in slimmer patients. Advantages of lipectomy over excisional techniques include reduced scarring and preservation of nipple innervations and lactation. However, it is less effective at correcting ptosis and can lead to a flatter breast shape. Suction lipectomy has been used successfully to treat macromastia in certain patient groups and this was not limited to small volume reduction. For example, in a series published by Courtiss1 volumes of up to 835 cc was removed from each breast, and in a study by Gray2 up to 2250 cc was removed with good outcomes and no reported complications.

With all pedicle designs there is a risk of poor breast-feeding potential and altered sensation, but the superior pedicle is particularly poor because the nipple-areola complex (NAC) is based on dermal rather than dermoglandular tissue. The perceived benefit of this technique is that ptosis may be reduced and projection improved because of inferior tissue excision. The inferior pedicle and central mound are reasonable choices for maintenance of sensation and breastfeeding potential. Around three-quarters of patients with inferior pedicle reductions will secrete postpartum milk.1

Würinger’s septum is part of a brassiere-like connective tissue suspensory system of the breast. It is a horizontal septum originating from the pectoral fascia along the fifth rib and merges with lateral and medial vertical ligaments. Within it are branches of the thoracoacromial, lateral thoracic, and fourth to sixth intercostal arteries. It also carries the main contributory nerve to the nipple (fourth intercostal). The lateral pedicle is most likely to maintain this septum although the central mound should also do so with careful dissection. In spite of this potential advantage, the lateral pedicle is less popular than the inferior, central, or superomedial pedicles because many patients need tissue removal from the lateral breast area and the pedicle design precludes this.1–3

Although periareolar approaches can be used for small mastopexy cases, their use for reduction mammaplasty is limited to very small reductions. Instead, their main role remains within mastopexy surgery or for gynecomastia resection. An inverted-T or Wise pattern relies on the skin to act as an external brassiere and support the breast. This can lead to bottoming out in the long term. For this reason, it receives criticism from proponents of the vertical scar techniques, which aim to reshape the breast and provide support from within using parenchymal pillar sutures. Skin is then redraped over the top. The ability to lactate after breast reduction is highly variable and seems to be affected by pedicle selection. Two issues require consideration: Is any amount of lactation possible, and is the volume adequate to successfully breast-feed? In theory, the ducts can recannulate after free nipple grafts, but the likelihood of successful lactation is negligible.1–3

When marking a breast for an inverted-T scar technique in breast reduction, the nipple is usually placed at the level of the IMF, which equates to Pitanguy’s line. However, in heavy pendulous breasts it is prudent to lower the nipple slightly to avoid overcorrection with the nipple ending up too high postoperatively. This is because once the weight of the breast parenchyma has been reduced, the elastic recoil of the skin will tend to lift the NAC above the estimated level. Correction of the high-riding nipple is difficult following uplift procedures and will create scars above the NAC. The breast meridian will provide a guide for the horizontal rather than vertical placement of the nipple. The vertical limbs should be 7–8 cm and are left this short to minimize bottoming out of the breast postoperatively. If they are too short however, there will be excessive skin tension during closure that can lead to wound dehiscence. The cut-out for the NAC should be slightly smaller than the NAC to minimize postoperative stretch. The vertical limbs of a breast reduction are straight but the horizontal limbs should be curvilinear with a lazy S-pattern, as this helps to reduce the medial and lateral dog-ears, while maintaining adequate skin at the T-junction. The use of curvilinear limbs on the lateral skin flaps increases the wound edge length on this side which can help any length discrepancy which exists compared with the IMF wound edge.1,2

Multiple studies have shown that infiltration with a solution of dilute epinephrine for breast reduction can significantly decrease intraoperative blood loss.1–5 This seems to be a fairly consistent finding across multiple studies and represents the major reproducible benefit of performing such a technique. Solutions that contain a local anesthetic have been shown to decrease postoperative pain in some studies. However, this was true only during the very early postoperative period. This is expected because the effects of local anesthetic agents are short-lived. Some studies have shown decreased operating time, presumably attributable to a blood-free operating field, whereas others have shown reduced postoperative drainage, but these results have not been consistent across the studies. Hospital stays at times trended toward shorter time periods, but they were not significantly different. Many surgeons will use intraoperative pectoralis blocks with infiltration of local anesthetic between pectoralis major and minor and further injections into serratus anterior. This can help reduce the opiate requirement post breast reduction.

The NAC can become compromised during or after a breast reduction procedure. This can result from poor arterial inflow leading to a pale nipple with no red bleeding evident or from venous congestion leading to a purple-colored nipple. Management of a compromised nipple is dependent on the likely cause and timing of the problem. Several key factors need to be confirmed. Patients should be warm and well perfused, with adequate blood pressure and urine output. The pedicle should be examined for signs of damage or kinking. Cessation of the procedure for a short time is advocated to assess these parameters and to allow the pedicle vasculature to recover from possible spasm. Local anesthetic infiltration with epinephrine may be contributing to an arterial inflow problem. If a patient is cardiovascularly optimized and the nipple continues to appear nonviable, then conversion to a free nipple graft may be sensible providing that all other factors have been addressed. If the compromise occurs during closure, or begins postoperatively, then it may be due to localized swelling causing vessel compression. Intraoperatively, the sutures can be removed to see if the nipple appearance improves. If so, loose closure may be indicated. If the compromise occurs postoperatively, it may be necessary to return to surgery, for example, to evacuate a hematoma (and reduce compression), to check for pedicle compression, or to convert to a free nipple graft. Nitroglycerine is a potent topical vasodilator that increases local blood flow by dilating arteries and veins. Although application of a topical nitroglycerine patch or ointment to the compromised nipple might be tempting, if the cause of inadequate perfusion is compromise of the pedicle for which the nipple is an indicator, then this will not be helped because the vascularity of the deeper tissues will not be affected.1,2

A number of studies have confirmed that there is no benefit in using drains in breast reduction patients with regard to hematoma rates.1–3 A randomized controlled study by Collis et al4 compared the use of drains in reduction mammaplasty with no drains in 150 patients and showed no difference in hematoma rates when a drain was or was not used. The incidence of wound healing or other complication was also unaffected by drain use. The American Society of Plastic Surgeons (ASPS) have published evidence-based guidelines5,6 on breast reduction and concluded that there is no correlation between volume excision and symptom relief. Most patients seek breast reduction surgery for functional reasons, although cosmesis is also often identified as a secondary concern.7 The functional symptoms of hypermastia are reported to be of comparable severity to those of a patient with a chronic medical condition, but there is no evidence to show that patients with a higher body mass index (BMI) (>25) have more severe symptoms. Reduction weights of greater than 800 g are associated with higher rates of complications including fat necrosis, wound dehiscence, delayed wound healing, seroma, and hematoma.