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BREAST REDUCTION

Anatomy

  • Breast structure

    • 2nd to 6th rib​

    • Lateral margin of sternum to the anterior axillary fold

    • Contains 15-20 lobes containing variable number of lobules

    • Each lobe drains into a mammary duct which terminates on the nipple

    • Lobules are separated by fibrous septa - fibres in upper portion of the breast are known as the suspensory ligaments of Astley Cooper

  • Blood supply​

    • Perforating branches of the internal mammary artery​

    • Pectoral branches of the thoracoacromial axis

    • Lateral thoracic artery

    • Lateral branches of 3rd-5th intercostal artery

  • Nerve supply​

    • Breast

      • Anterior cutaneous branches of the 2nd-6th intercostal nerves​

      • Anterior cutaneous branches of the 3rd-6th lateral cutaneous nerves

      • Supraclavicular branches of the cervical plexus

    • Nipple supply​​ by branches of 4th lateral cutaneous nerve

Anatomy

Terminology

  • Breast reduction

    • Technique involving the excision of breast skin and glandular tissue to reduce the breast size​

    • Often performed in conjunction with mastopexy techniques to lift breas tissue and nipple position

  • Mastopexy

    • Technique involving the excision of breast skin alone without or with little of the underlying gland​

    • Used to elevate breasts and the position of the nipple with a significant degree of ptosis

Patient assessment

  • Patient factors

    • Age​

    • Past medical history

      • Suitability for general anaesthesia or sedation​

      • Risk factors for wound healing

    • Previous breast surgery

      • Scarring​

    • Drug history

      • Anticoagulants​

      • Medications that affect wound healing​​

    • Smoking status

    • Family planning complete?

  • Breast

    • Current breast cup size​

    • Ideal breast cup size

    • Symptoms

      • Back or neck pain

      • Intertrigo leading to infections and rashes

      • Shoulder grooving due to bra strap

    • Limitation of function - sports

    • Oncology history

      • Lumps​

      • Skin changes

      • Nipple changes

      • Nipple discharge

  • Examination​​

    • True breast cup size​

    • Degree of ptosis (Regnault classification)

      • Grade 1 - Minor ptosis - Nipple at level of the inframammary fold (IMF), above lower contour of the gland ​and skin brassiere

      • Grade 2 - Moderate ptosis - Nipple lies below the level of the IMF, but above the lower contour of the gland and skin brassiere

      • Grade 3 - Severe ptosis - Nipple lies below the level of the IMF and the lower contour of the gland and skin brassiere

      • Pseudoptosis - Major portion of the breast mound lies below the inframammary crease, but the nipple remains slightly above the IMF

    • Measurements

      • Sternal notch to nipple distance​

      • Internipple distance

      • Nipple height (distance from IMF to nipple)

Terminology
Patient assessment

Breast aesthetics

  • Nipple areola complex (NAC)

    • Normal NAC - 38-45 mm diameter​)

    • Location at Pitanguy's point (transposition of IMF to anterior breast)

  • Penn numbers​

    • Sternal notch to nipple distance - 21cm​

    • Nipple to IMF distance - 6.9cm

  • Mallucci's concepts in aesthetic breast dimensions​

    • ​The proportion of the upper to the lower pole is a 45:55 ratio

    • The angulation of the nipple is upwards at a mean angle of 20° from the nipple meridian

    • The upper pole slope is linear or slightly concave

    • The lower pole is convex

Breast aesthetics

Surgical goals

  • Improve symptoms

  • Decrease breast volume (in breast reduction) and reposition the NAC in an anatomically correct position

  • Maintain vascularity and sensation to the NAC

  • Maintain parenchymal support for anatomic longevity

  • Resect excess skin without causing tension along closure line

  • Minimise scars

Surgical goals

Skin resection patterns

  • Generally independent of pedicle design

  • Inverted-T (Wise) pattern

    • Relies of skin integrity to shape and hold breast parenchyma​

    • Allows removal of large areas of skin in both horizontal and vertical directions

    • Best suited for large breasts or poor quality skin that cannot be remodeled

    • Very reproducible

  • Vertical pattern (Le Jour)​

    • Relies on parenchyma to shape skin​

    • Allows for less breast glandular tissue reduction than Wise pattern

    • No horizontal scar, therefore less scar than Wise pattern

    • Requires healthy skin for remodelling

    • Scar revision necessary in 10-15% of patients

  • Circumareolar (Benelli) pattern

    • Limited to breast reductions or mastopexy up to 2cm​

    • Does not allow for reduction of significantly enlarged NAC

    • May cause widening of NAC

    • Scar only around nipple, therefore less than Le Jour or Wise pattern

Skin resection patterns

Pedicle designs

  • Inferior pedicle technique

    • Enable removal of large volume of breast grandular tissue

    • Reliable technique for maintenance or improvement of pressure sensation to breast skin and NAC​

    • Pedicle width about 8cm

  • Superior pedicle​

    • Based on dermal pedicle of internal mammary perforator from the second intercostal space 

    • Less resultant ptosis​

    • Must thin pedicle to allow inset

    • Preserves breast projection

    • Poor breast feeding outcomes

  • Central pedicle​

    • Based on arterial and venous flow through glandular tissue

    • Modification of inferior pedicle​

  • Medial pedicle​

    • Dermal or dermoglandular pedicle based on internal mammary perforators from third intercostal space​

    • Suitable for moderate size reductions

  • Superomedial pedicle​

    • Based on internal mammary perforators from second and third intercosal space​

    • Safer for larger volume resection with NAC transpositions of up to 15 cm

    • May require debulking to improve inset

  • Lateral pedicle​

    • Based on perforators from lateral thoracic artery​

    • Vascularisation and sensation to NAC improved by maintaining continuity of Würinger's septum

    • Safe in large volume resections but not optimal for patients with excess axillary and lateral fullness

Pedicle designs

Preoperative marking

  • General markings​

    • Sit patient upright or standing​

    • Mark midline (from sternal notch to xyphisternum)

    • Mark IMF

    • Determine new NAC position (based on Pitanguy's point)

    • Measure sternal notch to nipple distance and nipple to midline distance to ensure symmetry

    • Optional:

      • Mark upper breast border​

      • Mark lateral breast border

  • Inverted-T pattern

    • Mark vertical limbs (7-8cm)

    • Connect vertal limbs to medial and lateral points of IMF marking in curvilinear line

  • Vertical pattern​

    • Mark vertical limbs by swinging breast medially and laterally​

    • Join vertical limbs at the meridian 2-4 cm above the IMF

Preoperative marking

Complications

  • NAC necrosis

  • Altered nipple sensation

  • Poor scarring

  • Wound complications

  • Poor breast-feeding

  • Fat necrosis

  • Asymmetry

  • Undercorrection or overcorrection

Complications
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