Recurrent or persistent macromastia can occur after breast reduction. This may be due to inadequate primary volume reduction, poor postoperative shape, and breast or nipple-areola complex asymmetry. Postpartum breast changes, weight change, and aging can also contribute to recurrent macromastia. The concern in these cases is the altered blood supply to the nipple-areola complex and the safety of nipple-areola complex transposition. Literature on the safety of repeated breast reduction is limited with conflicting approaches. This article discusses an approach to recurrent or persistent macromastia and outlines a modified breast reduction technique that is safe in cases of repeated breast reduction.
Key points
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Repeated breast reduction can be a safe and reliable procedure, even in cases of unknown initial pedicle, with little risk of vascular compromise of the nipple-areola complex (NAC).
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It is important to determine whether the NAC is adequately positioned, because this determines whether transposition of the NAC is required in addition to the inferior wedge resection and liposuction used for volume reduction.
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Liposuction is a useful adjunct in repeated breast reduction, because it allows for volume reduction while at the same time minimizing damage to the blood supply of the breast NAC.
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It is important to rule out malignancy as a potential cause of recurrent macromastia, particularly if the recurrence is unilateral.
Introduction
Breast reduction continues to be one of the most commonly performed procedures in plastic surgery, with more than 114,000 breast reductions performed in 2014, according to the American Society for Aesthetic Plastic Surgery.
Recurrent macromastia can be defined as the accumulation of excessive breast tissue after breast reduction. Excess breast tissue is a function of 2 factors: (1) the amount of excess tissue in the breast and (2) the location of excess tissue in the breast. Persistent macromastia describes continued breast tissue excess despite previous breast reduction.
Repeated breast reduction goes by several other names in the literature, including secondary breast reduction and revision breast reduction. All of these terms refer to volume reduction procedures after primary breast reduction. For the remainder of this article, the technique is referred to as repeated breast reduction. This article on the management of recurrent or persistent macromastia reviews key principles for repeated breast reduction and the authors’ approach to this potentially difficult problem.
Introduction
Breast reduction continues to be one of the most commonly performed procedures in plastic surgery, with more than 114,000 breast reductions performed in 2014, according to the American Society for Aesthetic Plastic Surgery.
Recurrent macromastia can be defined as the accumulation of excessive breast tissue after breast reduction. Excess breast tissue is a function of 2 factors: (1) the amount of excess tissue in the breast and (2) the location of excess tissue in the breast. Persistent macromastia describes continued breast tissue excess despite previous breast reduction.
Repeated breast reduction goes by several other names in the literature, including secondary breast reduction and revision breast reduction. All of these terms refer to volume reduction procedures after primary breast reduction. For the remainder of this article, the technique is referred to as repeated breast reduction. This article on the management of recurrent or persistent macromastia reviews key principles for repeated breast reduction and the authors’ approach to this potentially difficult problem.
Background
Despite reduction mammaplasty being one of the most commonly performed procedures in plastic surgery, the literature on outcomes after repeated breast reduction is limited to a handful of case series and case studies. Unfortunately, the sparse literature that does exist presents conflicting opinions and approaches to repeated breast reduction. Some investigators report significant complications in repeated breast reduction cases, including complete loss of the NAC, and advise that repeated breast reduction be approached with great apprehension. Some investigators even advocate liberal use of free nipple grafting in these cases. Meanwhile, other investigators have reported good results and believe repeated breast reduction can be a safe option, even in cases where the original mammaplasty technique is unknown.
A review of the case series published in the literature reports 88 patients having undergone repeated breast reduction, with 75 of these patients requiring transposition of the NAC ( Table 1 ). Lejour reported good results after vertical mammaplasty in 14 patients with no complications. She noted that liposuction was a safe technique that allowed for volume reduction without compromising vascularity to the NAC.
| No. of Patients (No. of Breasts) | No. of Complications | Nature of Complications | |
|---|---|---|---|
| Lejour, 1997 | 14 (28) | 0 | N/A |
| Hudson & Skoll, 1999 | 16 (28) | 8 | NAC necrosis (2) NAC compromise (1) Scar/dog ear (2) Wound-healing complications (2) Hematoma (1) |
| Losee et al, 2000 | 10 (?) | 5 | Delayed wound healing (3) Delayed nipple sensation return (2) |
| Patel et al, 2010 | 8 (16) | 3 | NAC necrosis (1) Seroma (1) Abscess (1) |
| Ahmad et al, 2012 | 25 (48) | 3 | Recurrent asymmetry (2) Cellulitis (1) |
| Sultan et al, 2013 | 15 (28) | 1 | NAC epidermolysis (1) |
Hudson and Skoll reviewed 16 repeated breast reduction patients, of which 8 required NAC transposition. Three patients in this cohort suffered vascular compromise of the NAC, with 2 leading to complete unilateral loss. Among these 3 cases, 2 occurred in the setting of a new dermoglandular pedicle (primary superomedial pedicle revised to inferior pedicle; primary inferior pedicle revised to superior pedicle) whereas the other occurred in the repeated use of an inferior pedicle. They suggested using the same pedicle, if known, when the NAC required transposition and otherwise free nipple grafting if the initial pedicle was unknown.
Losee and colleagues reported on 10 patients undergoing repeated breast reduction. A different technique/pedicle was used in 7 of the 10 cases, although only 3 cases involved complete transection of the previous pedicle. Five minor complications were reported in 3 patients, with no cases of NAC vascular compromise. Their group concluded that repeated breast reduction is a safe option when using either a similar or different technique.
Patel and colleagues reported a major complication rate of 37.5% in 8 patients undergoing repeated breast reduction. Furthermore, the investigators reported a 100% complication rate among the 3 patients where an inferior pedicle was used for both the primary and secondary procedure, including 1 case of NAC necrosis. They suggested that free nipple grafting might be the technique of choice for repeated breast reduction as there were no complications in the 2 cases included in their series.
Sultan and colleagues reported on 15 patients who underwent repeated breast reduction using a vertical scar with superior or superomedial pedicle after primary inverted T scar breast reduction. The initial pedicle was known in only 4 of the cases and all 4 were inferior pedicles. They reported 1 complication of unilateral NAC epidermolysis, which healed fully with conservative management. They concluded that this approach is safe and provides good aesthetic results.
A review of the literature reveals 20 documented complications among the 88 patients reported to have undergone repeated breast reduction. The majority of the complications (14 of 20) would be classified as minor complications (ie, delayed wound healing, scarring, and recurrent asymmetry) with only 3 patients experiencing complete NAC necrosis and 2 patients experiencing of NAC vascular compromise or epidermolysis. In all 3 reported cases of total NAC necrosis, an inferior pedicle was used for the revision procedure after either a primary inferior pedicle (2 cases) or a primary superomedial pedicle (1 case).
In 2012, the authors reported experience with repeated breast reduction in 25 patients using a modified technique for vertical scar reduction mammaplasty ; 21 patients required transposition of the NAC, and in approximately half of the cases the initial pedicle was unknown. Overall, 3 patients experienced minor complications; however, there were no cases of either partial or total NAC necrosis. The authors concluded that the use of vertical scar reduction mammaplasty with liposuction for repeated breast reduction is safe, even when the initial pedicle is unknown. Since this initial report, the authors have performed repeated breast reduction on more than 40 patients. To date, there have been no documented cases of either partial or total nipple necrosis using the authors’ modified technique for repeated breast reduction. Additionally, there have been no significant issues with skin necrosis or clinically detectable fat necrosis, which can also occur due to compromised blood supply during repeated breast reduction.
Etiology
When discussing the etiology of recurrent or persistent macromastia, it is important to elucidate the precise nature of a patient’s concerns. Patients presenting with macromastia despite previous breast reduction may be frustrated, having already invested time, energy, and money into a primary surgical procedure that did not meet their expectations. In any patient presenting with macromastia after previous breast reduction, it is important to clarify whether there has been any change in the size or shape of the breasts since the procedure as well as what those changes were and when they occurred. This information is critical in determining the cause of the breast volume excess.
Recurrent or persistent macromastia should be considered a problem of (1) inadequate volume reduction during the primary operation, (2) inadequate breast shape, or (3) breast tissue hypertrophy. Although only breast tissue hypertrophy represents true recurrent macromastia, it is important to consider these other etiologies when assessing a patient for repeated breast reduction because these help define the goals of surgery.
Inadequate Primary Volume Reduction
Inadequate volume reduction during the primary breast reduction is a frequent indication for repeated breast reduction. This may be due to technical factors but also may be related to a patient’s goals and expectations of the procedure. Although it is important to understand patients’ goals, it is equally important to manage their expectations preoperatively and ensure that they have a clear understanding the limitations of breast reduction surgery.
Patients often discuss desired postoperative breast size in relation to brassiere cup size. In 1984, Regnault and Daniel described an algorithm predicting the amount of tissue resection required to change the bra cup size based on chest circumference. Since then, several methods for predicting the resection amount in a reduction mammaplasty have been described, using either direct measurements or 3-D surface imaging. The authors, however, do not find these methods applicable or reliable, particularly given the lack of standardization between bra manufacturers.
Although it is helpful to ask patients preoperatively about their desired postoperative breast size, more importantly, it is more important to elucidate whether they prefer to be on the smaller or larger end of that range. Not only does this involve patients into the decision making process, it also helps determine how extensive a planned resection should be.
Inadequate Breast Shape
Pseudoptosis, or bottoming-out, was originally defined by Regnault as a breast shape where the gland descends inferior to the inframammary crease but the nipple remains above the crease. For patients who have just undergone a reduction mammaplasty to reduce and reshape the breast only to see this shape lost over time, pseudoptosis can be a significant concern. Pseudoptosis can also, in turn, make the NAC appear superiorly malpositioned. Although not true recurrent macromastia, because pseudoptosis represents a change in breast shape not an increase in breast volume, patients may not recognize or understand this difference.
To understand how this deformity may be prevented and corrected, an understanding of why it occurs is needed. Pseudoptosis can be thought of a failure of parenchymal support and skin support due to the excess weight of breast tissue. This failure may occur naturally with age, because the dermis naturally thins and loses elasticity, or it may occur after a primary reduction mammaplasty. Postoperative pseudoptosis is a commonly recognized deformity after inverted T scar/inferior pedicle breast reductions. Conceptually this makes sense, because the procedure relies on the skin to support the breast while leaving the weight of the breast in the inferior pole as the inferior pedicle. On the other hand, vertical scar/superior or superomedial pedicle breast reductions use parenchymal supporting sutures to cone the breast, removing the deforming weight of the inferior pole of the breast.
Studies looking at the 3-D shape of the breast over time following breast reduction demonstrate that shape changes in the breast occur over the first postoperative year with little change occurring thereafter, suggesting that pseudoptosis may be a relatively early postoperative occurrence.
It is important to recognize the difference between pseudoptosis and true ptosis. In cases of pseudoptosis the NAC is, by definition, in an acceptable position. Therefore, significant risk can be avoided by not attempting to reposition the NAC in these cases.
Another common problem after breast reduction can be asymmetry. Asymmetry is common in breast surgery and all patients have some degree of preoperative asymmetry, whether they realize it or not. It is important to point out these asymmetries to patients prior to surgery.
In some cases, the area of concern after breast reduction is the lateral chest wall as opposed to the breast. For patients, the transition between the lateral breast and lateral chest wall is poorly defined due to fatty fullness of the lateral chest compartment. In these patients, breast size and shape after breast reduction may be adequate whereas their concern is really with contour of the lateral chest wall. Liposuction and, in some cases, excision of the redundant skin may be indicated as opposed to repeated breast reduction.
Breast Tissue Hypertrophy
True recurrent macromastia, or the redevelopment of breast hypertrophy after breast reduction, is fortunately a rare occurrence. Although attempts have been made to define breast hypertrophy by breast volume or bra cup size, the authors suggest it is important not to attempt to correlate a patient’s breast size or body mass index with subjective symptoms. Studies have found no direct correlation between preoperative breast size, the severity of preoperative symptoms, and the postoperative degree of improvement of symptoms. Recurrent macromastia can be thought of as the development of breast enlargement after breast reduction, such that the patient experiences a significant impact on their functional symptoms and/or their aesthetic outcome. Not only does this remove all weight and size parameters from the definition of recurrent macromastia but also it provides a more person-centered definition of the condition.
There are several possible causes for recurrent macromastia, including weight gain and hormonal changes (eg, pregnancy and lactation). An important potential cause of recurrent macromastia that must never be overlooked is a neoplastic process in the breast, particularly if the recurrence is unilateral.
One unique cause of recurrent macromastia is juvenile hypertrophy of the breast, also referred to in the literature as virginal hypertrophy, juvenile macromastia, or juvenile gigantomastia. Representing approximately 2% of all breast pathology in adolescents, juvenile hypertrophy is characterized by a diffuse enlargement of the breast without the presence of a distinct mass or nodularity. Adolescents with this condition often suffer from significant functional and psychological distress, and the severity of these symptoms often necessitates surgical intervention prior to the end of puberty, which may contribute to the high recurrence rate. Although a full discussion of the management of juvenile hypertrophy of the breast is beyond the scope of this article, this is an important diagnosis to be aware of and to warn adolescent patients about prior to primary reduction mammaplasty.
Preoperative considerations
History and Physical Examination
Women presenting with recurrent or persistent macromastia range greatly in age, breast size, and body habitus. The goals of these patients also vary greatly, ranging from purely for symptom relief to purely aesthetic, with most on a spectrum somewhere between the two.
The functional assessment for these patients begins with a thorough review of the symptoms they have as a result of their macromastia. Kerrigan and colleagues identified 7 symptoms specific to breast hypertrophy (upper back pain, neck pain, shoulder pain, arm pain, arm numbness, rashes, and bra strap grooving) and found greater postoperative improvement in women reporting at least 2 of 7 physical symptoms all/most of the time. Although the authors find it helpful to review these symptoms with patients to determine their functional status, it is equally important to clarify which symptoms were present prior to their primary reduction mammaplasty and to what degree they changed after surgery.
The aesthetic assessment for these patients focuses on the size and shape changes of the breast since the primary breast reduction procedure. A patient with recurrent or persistent macromastia may be more bothered by breast shape or spreading of their scars than the actual size of the breasts, and this is important to clarify and discuss. The patient should describe what changes they have noticed in the size and shape of the breast, whether these changes have been symmetric, and over what time period these changes have occurred.
In patients with recurrent macromastia, it is important to assess for possible systemic causes. Patients should be asked about changes in their general health, weight changes, and if they have been pregnant and/or have breastfed since their previous surgery, because all these factors could contribute to changes in breast size. Although studies have demonstrated a decreased risk of breast cancer after breast reduction, patients presenting with recurrent macromastia should be asked about changes in the breast that may be concerning for breast cancer, including new lumps/masses, nipple discharge, and skin changes, as well as the timing and results of their most recent mammogram.
A thorough physical examination is important in the assessment of any patient presenting with recurrent or persistent macromastia. All patients should have their height and weight recorded at the time of presentation. The clinician should then perform a thorough breast examination, with a focus on skin and scar quality as well as breast size and shape. Any asymmetry between the breasts should be noted. Careful attention should be paid to the areas of excess glandular tissue and the presence of ptosis versus pseudoptosis. Finally, a screening breast examination should be performed, palpating the breasts for any abnormal masses.
Although little evidence exists regarding specific risk factors associated with repeated breast reduction, there is ample evidence regarding risk factors for primary breast reduction. As a result, the authors do not perform this procedure on active smokers due to the well-documented risks of smokers undergoing breast reduction, particularly regarding delayed wound healing and wound infection. Patients presenting for repeated breast reduction who are active smokers are instructed to quit smoking for at least 4 weeks preoperatively and 4 weeks postoperatively to decrease their risk of complications.
Previous Operative Records
All efforts should be made to obtain the surgical reports from the previous surgery; however, these records are often unobtainable. Even when the operative records are available, they may not contain enough detail to be of any use.
Informed Consent
It is important to have a thorough and well-documented discussion about the potential risks associated with repeated breast reduction. Although the authors believe this is a safe and effective procedure, the risk of complications is always a concern in revision surgery. Table 2 outlines the common and significant risks that can occur during repeated breast reduction.
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