Secondary Breast Reduction



Secondary Breast Reduction


Patrick J. Buchanan

Richard J. Greco



History

Breast reduction is one of the most common plastic surgical procedures performed in the United States with over 100,000 cases performed each year. A very small portion of these patients will suffer enough regrowth of their breast to have a recurrence of their symptoms and create secondary macromastia. There are many techniques described for the initial reduction operation, but many plastic surgeons have been wary of performing a secondary reduction because of the fear of nipple areolar complex (NAC) necrosis in the secondary operation. Historically, it has been taught and documented in the literature that the same pedicle must be used for all subsequent reductions to avoid NAC ischemia. Documented complication rates from subsequent reductions are between 20% and 60% (1,2,3,4,5). Free nipple graft techniques have been the mainstay of treatment for secondary reductions and are functional but leave the patient with no sensation, no potential ability to breastfeed, and hypopigmentation, frequently. Knowledge of the cause of the “recurrent” macromastia, the previous pedicle technique, and the relative position of the NAC will help to determine the best solution for the patient.


Indications

The indications for a secondary breast reduction are the same as for the primary procedure and include back and neck pain, breast pain, shoulder pain, headaches, shoulder grooves, intertrigo, and numbness and tingling in the arm or fingers associated with significantly enlarged breasts.


Contraindications

Secondary breast reductions can definitely improve the symptoms of a patient with recurrent symptomatic macromastia, but at the risk of poor healing and possible loss of the NAC because of inadequate blood supply. Therefore, it is very important to take into account the patient’s comorbidities including, but not limited to a history of significant nicotine use, diabetes, morbid obesity, other surgical scars that could potentially reduce the bloody supply to the NAC, poor oxygenation due to heart or pulmonary issues, and any other vascular disorders (i.e., scleroderma, vasculitis, etc.) that may add to the present risk of loss of NAC before proceeding forward with the secondary breast reduction.


Preoperative Planning

Preoperative planning for a secondary breast reduction should be similar to that of a primary breast reduction. Per the American Cancer Society guidelines, all patients over the age of 50 should have a screening mammogram within 1 year of the scheduled surgery. Once imaging is obtained, if warranted, the next decision is type of secondary reduction to perform. As stated previously, if the initial vascular pedicle is known then the secondary reduction should incorporate that pedicle in its design. However, if the initial pedicle is not known, then the surgeon must look at the NAC position.


When the NAC Is Already in the Correct/Ideal Position

In this group of patients we evaluate whether there has been a “bottoming out”/stretching of the lower pole of the breast or just an overall enlargement of a well-shaped breast. If the patient has a full, but well-shaped breast, liposuction of the breast alone could be an excellent option to reduce the size and symptoms while maintaining the overall shape and correct nipple areolar position. If the NAC is in the correct position, but the breast has
bottomed out: a resection of the lower pole of the breast in a transverse only or a vertical and horizontal resection is used to reduce the size of the breast and improve the shape of the breast.


Previous Operation Was Free Nipple Graft Technique

This group of patients does not have a definable previous pedicle of blood supply to the NAC. If the position of the NAC is correct, decide procedure as above. If the NAC is in the incorrect position, utilization of a secondary free nipple graft technique is an excellent choice.


Previous Pedicle of the NAC Is Known

If the previous pedicle is known, we would definitely include the blood supply in any procedure we design.


Previous Pedicle of the NAC Is Unknown

In patients where there is no operative report available and no way to know the actual blood supply to the nipple areolar complex from the previous surgery, we attempt to include as many potential significant blood supplies to the NAC as possible through our modified central mound (MCM) technique or free nipple graft technique.


Operative Technique

The surgical approach to the patient will depend on the present shape and size of the patient’s breasts, the relative position of the NAC, the desired size reduction, and the previous blood supply left intact to the NAC. For purposes of this chapter, we will only highlight the techniques used when the initial NAC pedicle is not known.


When the NAC Is Already in the Correct/Ideal Position


Liposuction

It is performed when the NAC is in the correct position, the initial NAC vascular pedicle is unknown, and the overall breast shape is ideal. Use a standard super-wet or tumescent liposuction technique. Ensure that the entire breast is addressed to avoid areas of over- or undertreatment, which can lead to breast distortion and asymmetries.


Inferior Pole Resection

This is performed when the NAC is in the correct position, but the breast itself has a “bottomed out” appearance with stretching of the inferior pole. In a horizontal scar–only technique, the inferior breast is marked and excised. The scar is then placed directly in the IMF, thereby leaving the NAC in its natural position. If excess skin remains, a vertical incision just below the NAC can be made to reduce the excess skin and breast tissue in the horizontal dimension.

Only gold members can continue reading. Log In or Register to continue

Aug 25, 2021 | Posted by in Aesthetic plastic surgery | Comments Off on Secondary Breast Reduction
Premium Wordpress Themes by UFO Themes