Reduction Mammoplasty

PROCEDURE OF THE DAY

Reduction Mammoplasty

Breast reduction or reduction mammoplasty is an outpatient surgical procedure[1] which involves the reduction in the size of breasts by excising fat, skin, and glandular tissue; it may also involve a procedure to counteract drooping of the breasts. As with breast augmentation, this procedure is typically performed on women, but may also be performed on men afflicted by gynecomastia.

The surgery, which the Food and Drug Administration has called "good medicine", is quickly gaining popularity. In 2005, over 113,000 women had breast reductions, an increase of 11 percent from 2004.[2]


Candidates

Breast reduction surgery is oriented toward women with large, pendulous breasts, especially gigantomastia, since the weight of their breasts may cause chronic pain of the head, neck, back, and shoulders, plus circulation and breathing problems. The weight may also cause discomfort as a result of brassiere straps abrading or irritating the skin.[2] For these reasons, the surgery is usually covered by insurance.[3] Even if physical discomfort is not a problem, some women feel awkward with the enormity of their breasts in proportion to the rest of their relatively smaller bodies. Except in unusual cases, this procedure is performed on individuals with fully-developed breasts, and it is not typically recommended for women who desire to breastfeed.

Males with common condition of gynecomastia may feel embarrassed and upset with their condition, usually developed during adolescence. They may get the surgery for restored confidence.[4] The surgical methods employed may vary depending on whether the breasts in the male patient are caused by adipose (fatty) or glandular tissue, and the degree to which any glandular tissue extends laterally along the sides of the torso.

A few celebrities are known for receiving breast reductions, such as Drew Barrymore,[5] Soleil Moon Frye,[6] Queen Latifah,[7], Sharon Osbourne[8], and Kerry Katona.[9]

Procedure

Doctors almost always perform breast reductions while the patient is under general anesthesia. During pre-operative visits, the doctor and patient may decide on new, usually higher, positions for the areolas and nipples.

For males, excess tissue may simply be removed through a tiny incision in each breast. This leaves minimal scarring.[4]

Patients may take a few weeks for initial recovery, however it may take from six months to a year for the body to completely adjust to the new breast size. Some women may experience discomfort during their initial menstruation following the surgery due to the breasts swelling.

Techniques

The traditional popular technique in North America bases the blood supply to the nipple and areola complex (NAC) from a central and inferiorly based attachment to the chest wall (an "inferior pedicle" or "central mound" technique), with variations of orientations of such pedicles described.[10] Better understanding of anatomy in terms of innervation to the NAC has made it more likely to leave both nipple sensitivity and capability to lactate for the patient as compared to other techniques of the past.[11] It is now being studied and debated as to which of the techniques results in a better quality of life for the patient in the long run.[10] Liposuction has been used as an adjunct to other breast reduction procedures for quite some time, but liposuction only techniques are not widely performed. All of the breast reduction techniques produce some degree of breast lift, but have a tendency to settle and stretch out the inferior skin envelope over time.
A comparison of post-surgery incision lines from the two most popular techniques

Inferior pedicle technique

The inferior pedicle technique, sometimes also known as a keyhole, inverted-T, or "Wise pattern" reduction, involves an anchor-shaped incision which circles the areola. The incision extends downward, following the natural curve of the breast. Excess glandular tissue, fat, and skin is removed. Next, the nipple and areola are moved into their new higher position.[12] A drawback of this technique is sometimes "square" looking breasts, but this is a common option for women with the largest, droopiest breasts. This is the most commonly performed technique in North America and produces predictable outcomes with larger reductions. Inferior pedicle techniques can also be performed through shorter scar incisions in some patients.

Vertical scar technique

The vertical scar techniques are gaining popularity in the United States due to their shorter scarring and projecting shape post-surgery. These types of procedures can involve the use of superior, inferior, medial or laterally based pedicles to the NAC. As compared to traditional incisions, they may have a limited or absent horizontal component. These procedures are best suited to smaller reductions with less excess skin to limit the scar length. Advantages include increased projection by the gathering of tissue medially, shorter scar length, and quicker surgery times. This technique keeps its results the best in the long term.[13] The breast is reduced through removal of the lateral and inferior tissues, leaving the upper pole mostly untouched.[14]

Horizontal scar technique

Horizontal scar techniques involve the use of a scar along the inframammary fold and a round cutout for the NAC. These procedures typically require a inferior or inferior-lateral pedical like traditional "Wise pattern" surgeries but eschew the vertical wedge excision. They permit a shorter scar option in women who are too large for vertical scar techniques. Advantages include the absence of a scar on the visible meridian of the breast and better scarring of the NAC inset. Disadvantages are the potential for "boxy" shaped breasts and poorer scarring that can be produced along the IMF.

Liposuction only technique

The liposuction only technique is used for women with breasts that are not quite as large as with the other procedures or in patients whom are anesthesia risks for longer procedures. For the best outcomes, women who choose this procedure have fatty, non-dense breast tissue with good skin and little ptosis (droop). As few women with larger breast possess those characteristics, the widespread use of this technique may be limited. The result is not as drastic as the other techniques, but it involves a quicker healing time and little scarring.[15] This is a technique typically used in conjunction with some direct excision of dense tissue for male gynecomastia surgery.

Free nipple graft technique

The free nipple graft technique is used primarily for high risk patients of ischemia to the NAC to reduce the chance of sloughing it postoperatively. Typical candidates would include diabetics, smokers, longer breasts approaching 20 cm from the IMF to the nipple, and breasts with significantly larger then normal resection requirements. In this procedure, the areola and nipple are completely removed for relocation and replaced as a skin graft higher on the breast. In these cases, sensation from the areola area will be lost and it eliminates the ability for lactation. This technique is sometimes used during surgery or postoperatively if the NAC viability is questionable. By eliminating the requirement for a pedical, this procedure allows significantly greater amounts of tissue to be removed safely.

Results

Reduction mammoplasty affords the recipient smaller, lighter, and firmer breasts. The surgeon may also reduce the size of and change the shape of the areola or nipples. Both men and women typically have restored confidence, as well.[4] It is often mentioned that patients who have received breast reductions are the happiest and most satisfied of all plastic surgery recipients.[3][2]

Risks

Possible issues include difficulty breast feeding, scarring, asymmetry, delayed wound healing, altered nipple sensation, fluid retention in the breast, altered erogenous function, and late changes in shape and recurrent ptosis (drooping.)

It may impair the likelihood of breastfeeding success due to the surgical disruption to the lactiferous duct system.[16][17] However, a number of studies have demonstrated a similar ability to breast feed when breast reduction patients are compared to control groups.[18][19][20]

Scarring from this procedure may be extensive and permanent. Initially, the scars are lumpy and red, but they gradually subside into their final smaller sizes as thin lines, slightly discolored. Though permanent, the surgeon can make the scars inconspicuous to the point that even low-cut tops may be worn without visible scars.

Cancer Prevention

Although not advocated as a cancer risk reducing procedure, a woman's risk of subsequently developing breast cancer will be reduced proportionately to the amount of breast tissue left.[citation needed]

The surgery can also make mammograms easier, since it may be difficult to get a decent mammogram reading with a great deal of excess breast tissue. Therefore, with less tissue, it can be easier for a doctors to get and interpret the results of a mammogram.[2] However, it is still typically recommended that patients receive new baseline mammograms 6 to 8 months after breast reduction to accommodate expected radiographic changes and give a new basis to which future imaging studies can be compared.

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