Noncancer Breast Surgery


Chapter 10

Noncancer Breast Surgery




Reduction Mammaplasty



1. Macromastia signs and symptoms


Back pain, shoulder and neck pain, trapezius m. hypertrophy, shoulder strap grooving, and inframammary fold (IMF) intertrigo


2. Preoperative considerations


Degree of ptosis and hypertrophy and desired postoperative size will help determine the amount of parenchymal reduction required and assist with selection of skin incision pattern and pedicle location.


Postoperative nipple-areolar complex (NAC) perfusion and sensation


Most important determinant of postoperative sensation is location of glandular resection and pedicle selection (lateral pedicle, inferior pedicle, or medial pedicle are best), not reduction volume, preoperative breast volume, skin incision pattern, and/or sternal notch-to-nipple distance.


Postoperative lactation


Rates of breast-feeding in women after breast reduction surgery are similar to those of child-bearing women who have not had breast reduction surgery.


Approximately 30% of women after inferior pedicle breast reduction breast-feed either exclusively or with formula supplementation.


Most important determinant of ability to breast-feed after breast reduction surgery is pedicle thickness


Pedicle type and reduction volume has no effect.


Impossible with free nipple grafting.


Smoking cessation


Breast measurements (see Figures 10.1 and 10.2)


Sternal notch-to-nipple distance


Nipple-to-IMF distance


Nipple-to-midline distance


Breast base width


Many advocate for preoperative mammography before surgery with any breast masses, breast complaints, or at-risk women (>35-40 years old [yo]) whose mammogram is over 1 year old.


Risk of occult breast cancer occurrence in reduction specimen is extremely rare (reportedly 0.2%).


When found, cancer is often early stage or in situ carcinoma.




3. Techniques


Suction lipectomy


Can be used alone in select patients


Contraindicated in patients with breast ptosis or who will likely require skin reduction


Advantages


Minimal scars


Rapid recovery and return to work


Decreased operative time


Minimal risk to nipple sensation/perfusion


Minimal risk to postoperative lactation


Disadvantages


Unable to pathologically examine lipoaspirate


High risk of inadequate reduction


Skin contraction unpredictable, leading to excess skin


Unable to correct breast ptosis


Traditional reduction mammaplasty


Combines a skin excision pattern with a pedicle to maintain nipple perfusion


Skin patterns include Wise pattern, keyhole, vertical, and no-vertical-scar techniques


Pedicle options include superior, medial, superomedial, inferior, lateral, and central pedicle


The inferior pedicle can achieve significant volume reduction and reduce the vertical dimension of the breast.


Can be used for all reductions, including moderate to severe reductions (>800 g)


Vertical mammaplasty


Uses a vertical-only skin excision that reduces scar burden and narrows the breast, thereby increasing projection


The initial breast shape is poor with a characteristic flattened, lower pole and inferior dog ears; however, this improves after 3 to 6 months.


This technique is generally used for moderate reductions (<800 g) or smaller but is contraindicated with a long pedicle length >9 cm because of concerns with nipple perfusion.


4. Complications: Risk factors include obesity, reduction volume >1000 g, and smoking.


Infection


Scarring


Long-term complication most associated with patient dissatisfaction


Seroma, hematoma


Greatest risk factor for hematoma is hypotensive anesthesia


Drains have not reduced the incidence of hematoma.


Fat necrosis


Characteristic finding: Development of delayed, firm, and nontender masses


Asymmetry


Skin loss and wound development (especially at the inferior T junction in Wise pattern reductions)


Most common complication in obese patients with large reduction volume


Under-resection


May require reoperation


NAC complications


Incidence <5%


Risk factors: Smoking, elevated body mass index (BMI), and long pedicle


Etiology


Intrinsic physiologic risk (obesity, smoking)


Excessive nipple-to-IMF distance/pedicle length and excessive sternal notch-to-nipple distance


Torsion of the pedicle


Excessive tension on the closure


Management


If immediately after reduction, pedicle exploration with release of tension


If pedicle release does not result in improvement, convert to free nipple graft


Be sure to graft to well-vascularized tissue and not the compromised skin flap or pedicle.


If nipple compromise occurs after early postoperative period, observation and conservative wound care



Mastopexy



1. Many similarities with reduction mammoplasty; however, primary goal is to lift the breast and correct breast ptosis


2. Breast ptosis: Relationship of the NAC to the IMF and lower contour of the breast (see Figures 10.3 and 10.4)


Regnault classification


Grade I: NAC within 1 cm of the IMF and above the lower contour of the breast


Grade II: NAC is 1-3 cm below the IMF but above the lower contour of the breast


Grade III: NAC >3 cm below the IMF and at the lower contour of the breast


Grade IV (pseudoptosis): NAC at the level of the IMF, but the majority of the breast volume has descended below the IMF


Increased nipple-to-IMF distance in setting of stable sternal notch-to-nipple distance


Sep 2, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Noncancer Breast Surgery

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