13 Elective Breast Surgery Abstract This chapter will review elective breast surgery, including breast reduction, augmentation, and mastopexy. The reader will be able to manage the large breast, the small breast, and assess and address complications. Keywords: macromastia, micromastia, reduction mammoplasty, breast reduction Six Key Points • Breast surgery should take into consideration the skin envelope and the breast parenchyma, and the footprint of the breast. • The nipple-areolar complex can be assessed for viability intraoperatively with fluorescein. • Breast implants should be chosen based on the base width of the patient’s breast footprint. • Implant-associated anaplastic large cell lymphoma is rare but most commonly presents with a late seroma. • Mastopexy and implant placement can be staged or performed together but have different risks depending on concurrence. • Treatment of Poland’s syndrome must adequately release fascial bands. 1. What is your approach to evaluating the patient with symptomatic macromastia (Fig. 13.1)? Begin with a focused history and note the patient’s current bra size and BMI, and a breast history, including how many times she has been pregnant, how many children she has, and how long she has breast fed—if at all. I note whether her breasts increased in size or decreased in size after breastfeeding. I ask about specific symptoms from the size of her breasts, such as back and shoulder pain, shoulder grooving from her bra straps, and intertrigo rashes, and how she has treated those conditions. I also ask about family history of breast or ovarian cancer, any breast masses or nipple discharge, if and when she had a mammogram. 2. When do you order a preoperative mammogram on a breast reduction patient? The current (2015) American Cancer Society (ACS) screening recommendations are the option of a baseline mammogram at age 40 years and screening beginning at age 45 years for healthy women. The ACS does not recommend stopping screening based on chronological age, but does note that screening may be stopped if a patient has a life expectancy of 3 to 5 years, has severe functional limitations, or has comorbidities that significantly affect life expectancy. In those cases, a patient would likely not be a candidate for an elective breast reduction. Alternative guidelines are the U.S. Preventative Service Task Force, an independent group that, under the auspices of the Department of Health and Human Services, used predictive modeling to aid in creating recommendations. Their recommendations are routine screening of average-risk women starting at age 50 years and continuing to age 74 years. 3. How do you examine a patient for a breast reduction? First, evaluate the breasts, noting any asymmetry and the grade of ptosis she has. Grades of ptosis, as classified by Regnault, are as follows: grade I—the nipple-areolar complex (NAC) is at the inframammary fold (IMF); grade II—the NAC is below the IMF; and grade III—the NAC is at the lowest portion of the breast. Pseudoptosis is when the NAC is in the appropriate position but the glandular tissue is below the IMF (Table 13.1). I palpate for masses and check for nipple discharge, and take the following measurements: chest circumference in inches, bust circumference in inches, breast width in centimeters, sternal notch to nipple in centimeters, NAC diameter in centimeters, and nipple to IMF in centimeters (Table 13.2). 4. The patient wants to know whether she can breastfeed after the procedure. What do you tell her? While there is no guarantee that one can breastfeed after a breast reduction, some studies have shown that equivalent percentages of women can breastfeed as those who have not had breast reduction, when the NAC is not attached as a free nipple graft. A free nipple graft would not allow breastfeeding. Fig. 13.1 A patient presents with complaints of large breasts. Table 13.1 Classification of breast ptosis
Questions
Breast Reduction
Grade I breast ptosis | Nipple at the level of the inframammary fold (IMF) |
Grade II breast ptosis | Nipple below the IMF |
Grade III breast ptosis | Nipple at the lowest contour of the breast |
Pseudoptosis | Glandular tissue below IMF |
Table 13.2 Breast measurements
Breast measurement | Units | Utility |
Chest and bust circumference | Inches | Can help assess whether patient is wearing correct bra size |
Breast width | Centimeters | Determines horizontal breast footprint. Wide breasts are less likely to have narrowing after reduction, and may appear as less of a reduction |
Sternal notch to nipple | Centimeters | A marker of ptosis as well as asymmetry |
Nipple to inframammary fold | Centimeters | A marker of ptosis, asymmetry, and can be used to determine whether a free nipple graft is needed |
5. What technique do you use for a breast reduction?
I use a vertical technique with a superomedial pedicle. The technique is a combination of the skin resection pattern, and the pedicle.
RATIONALE: A breast reduction pattern has two components: the skin resection pattern and the pedicle design. Skin resection patterns can be combined with different pedicle designs. There are two classic skin patterns: the Wise pattern, or “anchor scar,” and the vertical pattern (or “snowman”). The pedicle—the breast tissue that remains and through which the NAC receives its blood supply—can be based inferiorly, superiorly, medially, superomedially, laterally, or centrally. The inferior pedicle is very common, and many of the measurements to determine a free nipple graft are based on the inferior pedicle. A study by van Deventer demonstrated a robust blood supply to the NAC from the internal mammary artery.1
A posterosuperior pedicle is rarely used, but can be based off the anterior intercostal artery perforators.2
6. In which circumstances would you choose an inferior pedicle over a superior pedicle or superomedial pedicle?
Because the superior pedicle and superomedial pedicles raise the IMF, I would use an inferior pedicle if the IMF needed to remain the same or be lowered.
7. Under what circumstances would you perform a free nipple graft?
The indication for a free nipple graft are very large, very ptotic breasts, and—in some cases—tobacco use. While previous recommendations were to consider a free nipple graft with a nipple–IMF distance of greater than 18 cm that does not take into account patient variation, and that measurement speaks to inferior, rather than medial or superomedial pedicles.
8. The NAC is so large that you cannot resect all of the areolar skin in your pattern. What do you do?
The NAC skin that cannot be resected is left to allow for wound closure. I would talk with the patient preoperatively about the area, and could plan for staged resection after healing.
9. You perform a breast reduction using a superomedial pedicle and a vertical skin resection. Intraoperatively, the NAC appears dusky. What do you do?
With intraoperative NAC duskiness, the viability can be assessed using fluorescein.
10. On postoperative day 1, the NACs appear slightly dusky. What do you do?
First, I loosen the sutures. If the NACs do not become more pink, I would consider using nitropaste. If these do not work, I would take her back to the operating room (OR) and convert to a free nipple graft. A free nipple graft can be successful if performed within 48 hours of the original operation.
11. What do you tell the patient about a free nipple graft?
I would counsel her that she will lose sensation, and that breastfeeding (if she is planning on having more children) is not possible. Some hypopigmentation is expected with a free nipple graft. A free nipple graft is likely to be successful even if the NAC was congested on the pedicle because the graft can survive by imbibition until inosculation occurs.
Breast Augmentation
1. Describe what you expect to see in a patient who presents for routine cosmetic breast augmentation.
The patient would likely have small breasts without signs of significant asymmetry.
2. What do you offer her?
I would offer implants.
3. How do you decide which implants to use?
Saline implants feel less natural than silicone, but do not require monitoring the way that silicone implants require monitoring.
Food and Drug Administration (FDA) recommendations are that patients with silicone implants undergo MRI 3 years after placement of the implants, and every 2 years after that.
There have been no studies that have shown an association of implants with rheumatologic disorders.
4. How do you decide whether to place them in the subglandular or submuscular position?
In patients with a very thin skin envelope, I would recommend submuscular placement. In patients with a thicker skin envelope, subglandular implants are acceptable. This is determined by performing a pinch test with calipers at the upper pole where the implant will be. If there is less than 2 cm of tissue, a submuscular technique should be used. If the pinch is greater than 4 cm, a subglandular technique can be used.3 A modification of the subglandular approach is to place it under the fascia of the pectoralis muscle. This helps cover the edges of the implant, which can be palpable or visible in thin patients.
Assessing the five parameters of coverage, implant volume, implant dimensions, IMF location, and incision location as described in the “High Five Decision Support Process,” published by Tebbetts and Adams,4 will help in deciding whether to place the implant in the subglandular or submuscular position.
5. How do you decide the incision to use?
I prefer an inframammary incision, because it allows wide exposure, the incision is hidden underneath the curve of the breast, and there is less risk of contamination and sensory changes when compared with the periareolar and transaxillary approaches. In clothes, it is also covered. It is placed approximately 1 cm above the IMF and is at least 3 cm for a saline implant and at least 4.5 cm for a silicone implant.
6. Do you give antibiotics postoperatively?
There is no evidence to support giving antibiotics postoperatively for breast implant placement. There is currently only graded D evidence (level V) regarding continuation of antibiotic prophylaxis in expander implant reconstruction beyond the Surgical Care Improvement Project (SCIP) guidelines of 24 hours.5
7. The patient returns to clinic 7 weeks after the implant is placed, and her breast is hot and swollen. What do you do?
First, I would get a history and examine her, and find out if she has systemic evidence of infection, such as fevers, and I would establish a time line of symptoms course. I would perform a physical examination looking for fluid collections, and the extent of the erythema. If there is a fluid collection, I would take her to the OR. If there is no fluid collection, and the time course has been short, I would give a trial of IV antibiotics.
8. Which antibiotics would you use?
The specific antibiotics that would be appropriate are dependent on the nomograms at my institution. We treat with vancomycin and Zosyn for broad-spectrum coverage. If there is significant improvement after 24 hours, we transition to oral antibiotics, and use ciprofloxacin or levofloxacin.
9. She does not improve after antibiotics. What do you do?
I would explore the pocket and remove the implant. I would also send cultures from the OR.
10. After the implant is removed, it is replaced several months later. She returns to your clinic several years later and reports that one breast appears fuller than the other. What do you do?
I would evaluate for a seroma. If there is a seroma, I would send her for ultrasound-guided biopsy of the fluid collection and send the fluid for cytology to rule out anaplastic large cell lymphoma (ALCL).
11. She is worried about ALCL. What do you tell her?
The overall risk of ALCL is low, and ALCL is 2% of non-Hodgkin’s lymphomas. In a study in the Netherlands, there were a total of 11 cases of ALCL in the breast over a span of 17 years.6 There does appear to be an increased risk with breast implants, but there is evidence that ALCL associated with breast implants behaves differently than other systemic forms, and may be more indolent.7,8
12. She returns complaining that her breast is painful and firm. What do you do?
I would exclude a capsular contracture. Capsular contractures are risks with all breast implants, but textured implants have a lower risk of capsular contracture.9 They have, however, a higher risk of ALCL.
13. What are her risks for capsular contracture?
For subglandular placement with smooth implants, the relative risk is increased compared with both textured implants and subpectoral placement.9,10
Mastopexy
1. What technique do you use for a mastopexy?
The technique is determined by the characteristics of the skin envelope of the breast as well as the degree of ptosis. A small amount of ptosis with skin excess would be appropriate for a skin-only mastopexy.
2. The patient states that she would like implants with her mastopexy. What do you tell her?
Mastopexy is staged with implants. This allows the skin envelope to retract without placing considerable strain on it. It also allows patients to give me a better idea of what size they would like. It is possible to conflate ptosis with lack of volume, and many patients find that they are satisfied with the volume after the mastopexy.
3. After 3 months, she returns and one NAC is higher than the other. What do you do?
Three months is still too soon for revision. Even if there is an asymmetry, the scars will continue to mature and a revision will be in a dynamic, rather than, static field.
4. She comes back after another 3 months and it is still asymmetric. What do you do?
I would offer her a revision, and because it is easier to raise an NAC than lower one, I would raise the lower NAC to match the higher one.
5. Will she have to pay for the revision?
Yes. The policy on revision is disclosed in the preoperative consent and financial paperwork. Asymmetry is a possible postoperative event, and revisions require payment.
Tuberous Breast Deformity
1. Describe the defect.
The patient has a tuberous breast deformity with asymmetry, and the defect on the affected side is graded (Table 13.3). The anatomy is characterized by a vertically constricted base, hypoplasia of the breast tissue in one or more quadrants, an elevated IMF, and herniation of the breast parenchyma into the areola.
The tuberous breast is characterized by herniation of breast tissue into the areola, while the tubular breast has a constricted base but no herniation.
The critical features in the assessment of the tuberous breast are the extent of the skin envelope deficiency, and the extent of soft-tissue deficiency. A skin envelope deficiency will require that the skin be expanded, and a parenchymal deficiency can be addressed by auto-augmentation, implant reconstruction, or a combination of the two.11,12
2. What is your initial step in management?
I would first assess her development and confirm that her growth has stopped, and assess for Poland’s syndrome.
3. What is Poland’s syndrome?
Poland’s syndrome is a birth defect characterized by unilateral underdevelopment or agenesis of the chest wall, and can include agenesis of the sternal head pectoralis major muscle. It is also associated with syndactyly of the ipsilateral hand, and can be associated with shortened ribs.
4. Does the presence of Poland’s syndrome change your management?
It does not change the management of the breast deformity, but it does impact the counseling given to the patient and the expected results of surgery.
5. What do you offer the patient?
If there is not an adequate skin envelope, tissue expansion is an option. In type II and III breasts, I would discuss with the patient whether she is happy with the size of her breasts. If there is adequate tissue, Ribeiro’s technique combines a circumareolar incision with autoaugmentation using an inferior pedicle. The NAC is maintained on a superior pedicle, and an inferior flap is made by dividing the lower pole from the upper pole of the breast, making sure to disrupt the fascial ring. The inferior flap is then folded inferiorly to provide lower pole fullness. This technique can be modified; Fig. 13.2 shows the sequence of an autoaugmentation. An implant can be placed either subpectorally or subglandularly.12
6. Where do you place the implant?
I would place the implant in the subpectoral position. While it is acceptable to place the implant in the subglandular position, this position can result in a persistent deformity, and can sometimes cause the appearance of two IMFs.
Table 13.3 Grading of tuberous breast deformity
Tuberous breast grade | Hypoplasia |
I | Inferomedial quadrant |
II | Inferomedial and inferolateral quadrants, adequate areolar skin |
III | Inferomedial and inferolateral quadrants, adequate areolar skin |
IV | All quadrants |
Adapted from von Heimburg D, Exner K, Kruft S, Lemperle G. The tuberous breast deformity: classification and treatment. Br J Plast Surg 1996;49(6):339–345 and Grolleau JL, Lanfrey E, Lavigne B, Chavoin JP, Costagliola M. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg 1999;104(7):2040–2048
