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Breast Surgery

Introduction

Authors: Mia Demant, MD, Magnus Balslev Avnstorp, MD and Mia Steffensen, MD

Definition

Breast reduction is a procedure reducing the breast size and lifting the NAC to a higher position corresponding to age without compromising blood supply to the skin, nipple, and breast parenchyma. A number of breast reduction techniques are available, each having its unique combination of skin incision, pedicle planning, and resection pattern. In Denmark, the most common pedicle used is the superomedial, and the most commonly used techniques are:

The inverted T-technique: also called “Wise/anchor”-technique, or Orlando’s technique (1).

Figure 1 | The inverted T scar after an Orlando breast reduction.

The vertical scar technique: also called the “Keyhole”-technique or Hall-Findlay’s technique (2).

Figure 2 | The vertical scar after a Hall-Findlay breast reduction.

Purpose

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

Indications for surgery

In Denmark the indications for being a candidate for breast reduction at a public hospital are as following:

  • Skin irritations, macerations, intertrigo, and fungal infections under the breasts
  • 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 within the last 6 months
  • 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

Risks of reduction surgery

  • Necrosis of the NAC
  • The ability to breastfeed may be affected
  • Decreased skin sensitivity of the NAC and breast
  • Hematoma
  • Infection

Choosing the appropriate pedicle

The blood supply relies on the chosen pedicle; a superior, medial, inferior, or lateral pedicle for blood vessels and nerves is chosen. The pedicle is de-epithelialized for the preservation of the subdermal blood supply to improve circulation for the NAC. As mentioned, in Denmark surgeons often rely on the superiormedial pedicle. The benefits and drawbacks of various pedicles are presented in Table 1.

Benefits and drawbacks of different pedicle techniques

BenefitsDrawbacks
Lateral pedicleLarge volume resection possible
Breast feeding ability
Limitation of lateral debulking
Inferior aesthetic outcome
No dual bloodsupply
Inferior pedicleIncreased NAC sensibility
Large volume resection possible
High risk of bottoming out
No dual blood supply
Superior pedicleLeaves upper-pole fullness
Maintains breast projection
Impairment of NAC sensibility
Limited to small resection
No dual blood supply
Medial pedicleIncreased NAC sensibility
Larger volume resection possible
Less risk of bottoming out
No dual blood supply
Superomedial pedicleIncreased NAC sensibility
Large volume resection possible
Less risk of bottoming out (an appearance of the bottom of the breast tissue bulging downward)
No dual blood supply
Central pedicleIncreased NAC sensibility
Large volume resection possible
Breast feeding ability
Less risk of bottoming out
No dual blood supply

Acknowledgments

Illustrators: Christian Paaskesen, med.stud., Emma Tubæk Nielsen, med.stud.

References

  1. Brown RH, Siy R, Khan K, Izaddoost S. The Superomedial Pedicle Wise-Pattern Breast Reduction: Reproducible, Reliable, and Resilient. Semin Plast Surg. 2015 May;29(2):94–101.
  2. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg. 2002 Jul;29(3):379–91.
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