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Breast Surgery

Breast reduction

Authors Mia Demant, MD, Magnus Balslev Avnstorp, MD, Mia Steffensen, MD, Tine Damsgaard, MD, PhD, Professor

Definition

Reducing the breast size and lifting the NAC to a higher position corresponding to age without compromising blood supply to the skin, nipple, and parenchyma.

Purpose

To relieve the patient’s physical and psychological difficulties related to her breast size and weight.

Indications for surgery (at a public hospital)

  • Skin irritations, macerations, intertrigo and fungal infections in the IMFs.
  • Heavy, pendulous breast – the reduced amount of breast tissue should be at least 400-500 g on each side
  • Neck- and back pain related to the weight of the breasts.
  • Indentations on the shoulders from bra straps.
  • Limitations on physical activity due to breast size and weight.
  • Abnormal ptosis due to age.
  • Psychological affection due to unwanted attention to the large breasts.

Contraindications

  • Smoking
  • BMI > 25
  • Age < 18 years (lower age can sometimes be accepted if the patient’s difficulties are of  significant size)

Pre-operative assessment

  • All women ≥ 35 years of age must have normal mammography, that is no more than 6 months old
  • Any palpable breast lumps must be examined by mammography and ultrasound before surgery
  • The skin incision pattern and pedicle (most commonly superiomedial pedicle) is chosen pre-operatively

Choosing the appropriate breast reduction technique

There currently exist several breast reduction techniques with various pedicle options. The blood supply relies on the chosen (de-epithelialized) pedicle; a superior, medial, inferior, or lateral pedicle for blood vessels and nerves is chosen. In Denmark, surgeons often rely on medial-superior pedicle.

Pedicles, here shown with a keyhole-incision. A: Inferior, B: Central, C: Superior, D: Lateral, E: Medial.

The pedicle

The blood supply relies on the chosen de-epithelized pedicle. A superior, medial, inferior or lateral pedicle for blood vessels and nerves is chosen. In Denmark, we often rely on the medial-superior pedicle.

Figure 1 – Pedicles, here shown with keyhole incision. A: Inferior, B: Central, C: Superior, D: Lateral, E: Medial.

Vertical scar technique

Also called: Keyhole pattern

Involve typically a shorter scar and is restricted to cases of mild mamma hypertrophy. The pedicle is placed supero-medial. The incision lines form a snowman figure as shown in the following pictures. The scars will be located around the nipple areola complex and vertically passing the new inframammary fold.

An example is the “Hall Findley Technique”, which relies on a supero-medial pedicle. Excision of medial and lateral parenchyma beneath the skin is performed.

Hall Findley Technqiue

The inverted T-techniques

Also called: Wise-pattern or Anchor pattern

Involve typically a longer scar, and is suitable for severe mamma hypertrophy. It is possible to excise a bigger amount of breast tissue in both the medial and lateral aspect of the breast. The pedicles can have an inferior, medial, or superomedial orientation. The incision lines are shown in the following pictures and the resulting scars are located around the nipple areola complex and are forming an inverted T on the lower aspect of the breast including the IMF.

An example is the “Orlando Technique”, which relies on a supero-medial pedicle. Excision of skin and parenchyma laterally to the axilla and medial is performed.

The Orlando Technique

The postoperative regime

  • On the recovery ward observe for capillary response at the NAC and palpate for hematomas.
  • The patient may be discharged at the day of surgery or the following day
  • No removal of sutures is needed as they are all absorbable
  • No sports for at least 4 weeks.
  • Wearing of a supportive bra
  • May benefit from weightloss and training of muscles in neck, back and shouders
  • Post-operative control and photos after 3 months
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