Plastic surgery

PART VI

BREAST

CHAPTER 56  VERTICAL REDUCTION MAMMAPLASTY

ELIZABETH J. HALL-FINDLAY

The key to a good breast reduction is in combining an aesthetic sense of an ideal breast with an understanding of the anatomy and science of tissue healing. Each surgeon must adapt different designs to different patient presentations. No single technique is applied to all breasts.

The term “vertical” is misleading because it only applies to the final scars. Confusion is generated by equating the choice of the skin resection pattern with the choice of pedicle used to transfer the nipple–areolar complex. Different pedicles can be combined with different parenchymal resection patterns and both can be combined with different skin resection patterns.

Because the vertical skin resection pattern is often associated with a superior or superomedial pedicle and because the inverted-T skin resection pattern tends to be associated with an inferior or central pedicle, the terms are often used without clear distinction. This chapter outlines how to design and perform a medial or superomedial pedicle with a Wise parenchymal resection pattern and a vertical skin closure.

Although some skin types can be effective as a skin brassiere, skin expansion techniques have taught us that skin and dermis stretch when tension is applied. The approach described in this chapter does not rely on skin to hold the breast shape. The concept of the inferior vertical wedge resection combined with a tension-free parenchymal closure and a tension-free skin closure will result in good healing and an enduring breast shape.

ANATOMY

The breast is a subcutaneous structure that originates at the fourth interspace. It is attached to the skin at the nipple and is only loosely connected to the pectoralis fascia. The breast is held in place by two zones of adherence: 1) the skin–fascial attachments at the inframammary fold (IMF) and 2) The skin–fascial attachments over the sternum (akin to the gluteal crease and the sacral skin attachments). The breast is not “attached” to the pectoralis fascia. The lateral and superior breast borders are relatively mobile while the inferior and medial borders are held in place by skin adherence to deep fascia.

Blood Supply

There is a deep artery (with venae comitantes) that emanates from the fourth branch of the internal mammary artery and perforates through the intercostals and the pectoralis muscle and enters the breast just medial to breast meridian above the fifth rib (Figure 56.1A). This is the main blood supply to an inferior pedicle (and the inferior flap used in a mastopexy). As pointed out by Ian Taylor, the rest of the breast blood supply is superficial. This makes sense as one envisions breast growth from a small subcutaneous fourth interspace structure which has a deep artery and vein. As it grows and develops, the breast pushes the arteries and veins contained in the subcutaneous tissue outward.

The main vascular supply of the breast (both deep and superficial) originates from the internal mammary system. The veins and arteries in the superficial system do not travel together. The veins are located just beneath the dermis and they tend to drain superomedially. They can often be seen through the skin. The arteries start out from a deep level at the periphery of the breast and then travel in the subcutaneous fat.

Because the arteries are superficial around the curve of the breast, the design of the pedicle for the nipple–areolar complex can be dermal rather than dermoglandular, but care must be taken to preserve the deep tissue around the periphery of the breast. Because the veins lie just under the dermis, it is important to maintain a dermal connection to most pedicles.

The artery to a superior pedicle originates at the second interspace. It travels laterally and is the same vessel that supplies a deltopectoral flap. There is a large descending branch, which curves over the breast and enters the areola about 1 cm deep to the skin and close to the breast meridian.

The artery to a medial pedicle originates at the third interspace and curves up over the breast in the subcutaneous tissue. A true superomedial pedicle will contain both the artery to a superior pedicle and the artery to a medial pedicle. This is also an ideal pedicle because most of the venous drainage is superomedial. The vessels are superficial at the level of the areola but deep close to the sternum.

The artery to a lateral pedicle comes from the superficial branch of the lateral thoracic artery. It can enter the breast at a fairly low level and a lateral pedicle should be designed with a low base to ensure that the artery is included. This artery is also deep at the periphery of the breast but becomes more superficial closer to the areola. The arteries to both a superior and a lateral pedicle can be easily located with a Doppler.

The deep artery and vein from the fourth interspace supply an inferior or central pedicle. There are vessels that curve around the inferior aspect of the breast from the fifth (and possibly sixth) interspace and enter the breast at the level of the IMF. They have a deep origin and curve around to enter the breast in the superficial subcutaneous tissue.

Nerve Supply

Innervation to the nipple–areolar complex is said to be provided by the lateral branch of the fourth intercostal nerve (Figure 56.1B). Although this is true, it does not constitute the only nerve supply. The lateral branch divides into both a superficial branch and a deep branch that supply the nipple and areola. The superficial branch is carried in a lateral pedicle. The deep branch travels along the surface of the pectoralis fascia and then turns upward toward the nipple at the breast meridian. This is interesting because it means that any full-thickness pedicle should be able to incorporate this deep branch. There are also medial branches of the intercostal system that run superficially and supply innervation to a medial pedicle. Supraclavicular branches run superficially and supply a superior pedicle.

A study by the author of over 700 breast reduction patients who had either a full year follow-up or who had already achieved full sensation were assessed. There were 58 breasts with superior pedicles, 147 breasts with lateral pedicles, and 1,206 breasts with medial pedicles. Patients were asked to compare their preoperative and postoperative sensation on a visual analog scale. Sixty-seven percent of superior pedicles, 77% of lateral pedicles, and 85% of medial pedicles recovered normal to near-normal sensitivity.

Ductal Preservation

There are approximately 20 to 25 ducts that enter the nipple. Each duct is fed by glandular breast parenchyma. Although dermal pedicles may preserve arterial, venous, and nerve supply, it is unlikely that dermal pedicles will retain much breast feeding potential. Ducts may reconnect to some degree but dermoglandular pedicles will preserve more connections to glandular and ductal tissues. There is a good study by Norma Cruz-Korchin that shows no difference in breast feeding in large-breasted patients with or without breast reduction.

FIGURE 56.1. Anatomy. A. Blood supply. The arterial supply is superficial (ABD) except for the deep perforator (C) that comes through the pectoralis muscle. The deep perforator penetrates into the breast with its venae comitantes at the fourth interspace, while the other arteries curve up in the subcutaneous tissue superficial to the breast mound. The veins lie just under the dermis and are quite separate from these superficial arteries. B. Nerve supply. The main innervation to the nipple and areola is from the lateral fourth intercostal nerve. It should be noted that there is a deep branch that courses just above the pectoralis fascia as well as the more superficial branch. This branch can provide sensitivity in several full-thickness pedicles. There are also medial intercostal branches that supply innervation.

DESIGN

There has been considerable reluctance to adopt the vertical skin resection patterns in breast reduction surgery (Figure 56.2). This is based on a fear that the shape takes a long time to finalize and that there is a higher revision rate due to inframammary bunching. Neither is true.

The key is to leave a Wise pattern of parenchyma behind and to close both the pillars and the skin without tension. It makes more sense to remove the heavy inferior pole than it does to remove the upper pole. The inverted-T patterns tend to use the skin brassiere to hold the breast shape. Placing the skin repair under tension inevitably leads to wound healing problems. On the other hand,the vertical patterns tend to use the breast parenchyma to provide and maintain the shape.

Most inverted-T–type breast reduction patterns remove a horizontal ellipse of skin and breast tissue and involve chasing dog-ears medially and laterally. Most vertical-type breast reduction patterns remove a vertical ellipse of skin and breast tissue and involve chasing dog-ears superiorly and inferiorly. Lateral and medial dog-ears can sometimes be difficult to prevent and treat and the horizontal resection sometimes leaves a boxy breast shape with a wide base.

The vertical wedge resection allows better narrowing of the breast base and increases breast projection, while the horizontal approaches tend to flatten the breast. To prevent pseudoptosis in the inverted-“T” approach, the vertical skin length from nipple to IMF is restricted to about 5 cm. Although some coning of the breast tissue occurs with the inverted-T patterns, the nature of the resection plays a minor role in shaping. The increased length of the vertical scar is needed to accommodate the increased projection that results from the vertical wedge resection approach.

FIGURE 56.2. Pedicles and skin resection patterns. The skin resection pattern and the pedicle used for the nipple–areolar complex are assessed separately. Various combinations are available. A. Skin resection patterns. B. Pedicle choices.

The choice of pedicle will also influence the resultant breast shape. The superior, superolateral, and superomedial pedicles will rely less on the skin brassiere to hold the shape. The inferior pedicle may give way to gravitational forces. The choice of pedicle will influence the parenchymal resection pattern. Any type of skin resection pattern can, however, be used with any type of pedicle. A “J,” “L,” or small or large “T” can be added to remove any excess loose skin if needed.

VERTICAL BREAST REDUCTION USING THE MEDIAL OR SUPEROMEDIALLY BASED PEDICLE

The following describes a vertical skin resection pattern using either a pure medially based pedicle or a superomedially based pedicle for the nipple–areolar complex (Figure 56.3).

Parenchymal resection: The parenchymal resection follows the Wise pattern (not just the keyhole opening) with both a vertical wedge resection and a horizontal resection of tissue below the pattern. The key is to leave a Wise pattern of parenchyma behind. When the Wise pattern (designed after a brassiere) is closed, the tissue is coned and the result is a breast with good projection and no tension on the pillar closure. It is believed that this resection pattern best resists the deforming forces of gravity over time.

Vertical skin resection pattern: The vertical skin excision is a vertical ellipse. The skin is not used as a brassiere and is only used to adapt to the new parenchymal shape. Because an elliptical excision lengthens when closed and because the IMF rises with this type of procedure, it is important to keep the skin resection pattern high on the inferior mound because some breast skin will become chest wall skin. This is important to prevent the scar from extending below the new IMF.

Medially based pedicle: A true medial pedicle is easy to inset. The inferior border of the medial pedicle becomes the medial pillar and the pedicle rotates into position without any compression or kinking. The fact that the whole base of the pedicle rotates gives an elegant curve to the inferior aspect of the breast.

FIGURE 56.3. Design of the skin resection pattern (outlined in red), the medially based pedicle (colored blue) and the parenchymal resection pattern (crosshatched). The parenchymal resection follows a Wise pattern and the skin resection pattern looks like a snowman. The base of the pedicle can be carried up just lateral to the 12 o’clock position to create a true superomedial pedicle which then includes two arterial supplies. Tissue deep to the pedicle (which does not contain the arteries) may need to be excised to allow easier inset of a true superomedial pedicle.

Superomedially based pedicle: A superior pedicle can be difficult to inset because it usually needs to be folded. It is often necessary (and safe) to thin the pedicle to allow for an easier inset but this can lead to inferior hollowing of the breast with a concave lower breast pole at the end of the procedure. Combining a superior and medial pedicle can include both of the arteries from the second and third interspaces and therefore provide more dependable circulation. The superomedial pedicle can be backcut laterally and if the pedicle is difficult to inset, the deeper tissue (which has very little blood supply) can be removed to prevent kinking or compression. When creating a pedicle, the surgeon will often note that the bleeding occurs within the first centimeter of depth and there is very little bleeding as the dissection progresses toward the pectoralis fascia.

Markings

The key to marking a vertical breast reduction is to understand what happens to the breast after reduction and where the ideal nipple position should be. The upper breast border and upper pole of the breast will not change. Projection will improve, but the breast cannot be elevated higher on the chest wall.

It is important to understand (and point out to the patient) that some patients are “high-breasted” and some patients are “low-breasted.” The breast footprint varies from patient to patient in both vertical and horizontal dimensions. The upper breast border will not change but the IMF can rise with a medial pedicle, vertical breast reduction (and it can drop with an inverted-T, inferior pedicle reduction).

It has been recommended by many surgeons (including the author) to use the IMF as a guide to the ideal nipple position. Although this can help, the upper breast border is a more accurate landmark. There can be considerable variation in IMF level from patient to patient (and from breast to breast in the same patient). The upper breast border is the junction of the chest wall and the breast and it lies anterior to the depression just below the preaxillary fullness. The surgeon’s hand can be used to push the breast up from below to better determine its level. It is often marked by the upper extent of the striae.

Determination of New Nipple Position. The ideal nipple position in an average “C” cup breast is about 10 cm below the upper breast border on the ideal breast meridian—which is about 10 cm from the chest midline (as drawn through the air and not around the breast). The breast meridian should not be drawn through the existing nipple position but it should be drawn through the ideal nipple position. Although 10 cm is a good guide for a vertical breast reduction, somewhat more lateral will be better for an inverted-T breast reduction because the breast base is narrowed more in the vertical approaches.

The surgeon should be able to visualize the final result. The upper pole of the breast will not change and the goal of the breast reduction will be to remove the excess inferior and lateral breast tissue. Measurements have shown that the nipple position from the suprasternal notch will remain as marked. It is a mistake to mark the nipple at an arbitrary distance from the suprasternal notch. In high-breasted patients, the ideal position might be 22 cm but in low-breasted patients it may be at 26 cm. If the nipple is marked at 24 cm (for example) from the suprasternal notch preoperatively with the patient standing, the measurement will remain the same postoperatively. The upper breast border can be raised using an implant by about 2 cm but it cannot be raised in a pure breast reduction—even when breast tissue is sutured up to chest wall.

It is best to err on the side of marking the new nipple position too lateral rather than too medial. An ideal nipple is best placed to face slightly lateral and slightly inferior. Caution: it is almost impossible to lower a nipple that has been placed too high. It is much easier to raise a nipple that is too low. When a patient lacks upper pole fullness, it is best to lower the new nipple position so that it is not placed on an upper concavity giving an appearance of glandular ptosis.

In cases of asymmetry, it is best to place the new nipple position slightly lower on the larger side. This takes into account the fact that closure of a wider elliptical resection will push the ends of the ellipse further. This is not something that happens with an inverted-T type of reduction.

The new nipple position should be placed at the most projecting part of the breast. The nipple should be “centralized” not “centered” on the breast mound. The nipple should be one-third to one-half the way up the breast mound and it should be slightly lateral to the breast meridian.

Skin Resection Pattern

Areolar Opening. The new nipple and areola are best marked with the patient standing. Although some intraoperative adjustments can be made to make sure the areola is circular, the landmarks are distorted in the supine position. The surgeon can stand back during the markings and visualize the final result because the upper portion of the breast will not change.

The areola is marked about 2 cm above the new nipple position. An ideal areola is about 4 to 5 cm in diameter. The areola can be drawn freehand or with a template. It is not necessary to make the opening “mosque” shaped—it is actually better to take more skin vertically rather than horizontally. A good template is a large paper clip—folded out it measures 16 cm. A 16 cm circumference matches a 5 cm diameter areola and a 14 cm circumference matches a 4.5 cm diameter. The actual design is not as important as making sure that the final shape is circular. It can be adjusted at the end of the procedure.

Vertical Skin Resection Pattern. In this technique, the skin is not important in shaping the breast. Only enough skin is removed to prevent skin redundancy. The skin is not being used as a skin brassiere and it is unnecessary—and detrimental—to make the skin closure tight.

The vertical limbs can be drawn similar to that which would be drawn for an inverted-T or Wise pattern reduction. These can be determined by pushing (and slightly rotating) the breast medially and then laterally to line up the vertical limbs with the previously drawn meridians in the upper and lower chest wall areas.

Instead of extending the vertical limbs laterally and medially as would be done in an inverted-T–type Wise pattern, the vertical limbs are joined to each other well above the IMF. The final shape of the skin resection pattern with both the areolar opening and the vertical skin resection is much like a child’s snowman. The body is round with a smaller round head on top. Some surgeons have made the vertical resection come down as a “V” in order to limit the skin dog-ear, but it is important when doing this to remove adequate subcutaneous tissue inferiorly. A postoperative pucker is more often a result of excess subcutaneous tissue rather than excess skin.

The skin resection pattern should terminate well above the existing IMF. There are two reasons for this. First, the parenchyma and skin are excised as a vertical ellipse and closure results in lengthening of the incision. The closure can then push the scar below the fold. Second, when the parenchyma is removed below the Wise pattern horizontally (in addition to the resection along the vertical ellipse), the IMF will often rise. If the fold rises, the scar can fall below the new IMF. If these two factors are not taken into account, the scar might end up extending onto the chest wall skin that was previously lower pole breast skin. On average, the incision should stop at least 2 to 4 cm above the IMF in a small to medium (300 to 600 g) reduction.

Pedicle Design. A true medial pedicle has a base width of about 8 cm with half of the base up into the areolar opening and half below onto the vertical limb. A medial pedicle can be either dermal or dermoglandular but it should be beveled out peripherally because the artery (from the third interspace branch of the internal mammary artery) is deep when it comes out from around the sternum. It then travels up around the breast parenchyma into the superficial subcutaneous layer.

A pure medial pedicle will appear to be superomedial when the patient is standing, but the blood supply is medial. A full-thickness medial pedicle is more likely to incorporate the deep branch of the lateral fourth intercostal nerve and it will contain more ducts than a dermal pedicle.

A full-thickness pedicle is also preferable because of the thickness needed for the medial pillar. The inferior border of the medial pedicle becomes the medial pillar as the pedicle is rotated up into position. It is better if the pedicle is not thinned.

A true superomedial pedicle has a design similar to a medial pedicle but the base extends superolaterally across the breast meridian past the 12 o’clock position on the new areolar opening.This will include not only the medial pedicle artery but also the significant descending branch of the internal mammary artery from the second interspace. Doppler examination of 83 patients (160 breasts) by the author showed that this artery was very close to the new breast meridian with 59% just medial and 24% just lateral to the meridian. The remaining 17% were at the meridian itself.

A superomedial pedicle is more difficult to inset but it can be safely thinned because the artery lies at most 1 cm below the skin surface. Thinning the pedicle deeply will allow that superior part to fold without compromising the second arterial input. This second artery adds a safety factor, especially in long pedicles but it will be the longer pedicles that are more difficult to inset.

The lateral pedicle design was initially chosen by the author because it was presumed to have better sensitivity (it did not) and it is easy to inset, but the excess lateral breast tissue that requires resection forms the base of the pedicle. This prevents adequate lateral resection. Any attempt to pull the lateral breast tissue medially in order to correct the lateral fullness is unfortunately ineffective as the tissue tends to slide back, resulting in recurrent lateral fullness.

It may be tempting to try to use the pedicle to push excess tissue superiorly in order to increase upper pole fullness. Unfortunately, the increase is temporary and bottoming-out always occurs.

Parenchymal Resection Design. The pedicle chosen will determine to some extent the pattern of the parenchymal resection. For example, using an inferior pedicle means that the breast tissue is removed superiorly. For many of the vertical patterns, the breast tissue is removed inferiorly as a vertical wedge.

The principle that the vertical limbs in an inverted-T should measure only 5 cm does not apply to the skin in the vertical techniques, but it is a useful concept for the parenchyma. Keeping the pillar height at about 7 cm gives an ideal breast shape. To keep the pillars relatively short, the remaining parenchyma is removed horizontally below the pillars along a Wise pattern.

Once the markings are complete, it helps to draw the inverted-T or Wise pattern on the skin to guide the parenchymal resection. The tissue above is maintained to shape the breast and create the breast pillars. The tissue below—both vertically and horizontally—is removed. The vertical wedge is excised directly. The horizontal areas are often removed by beveling out the resection and then tailoring the excision with liposuction.

Operative Technique

Infiltration. Vasoconstriction is helpful. Infiltration along the inferior aspect and the base of the breast of about 40 mL per breast of lidocaine 0.5% with 1:400,000 epinephrine will reduce bleeding during parenchymal resection. Unfortunately, infiltration along the incision lines can result in small hematomas because of the numerous superficial veins just below the dermis.

In obese patients, it is advisable to infiltrate about 500 to 1,000 mL of a tumescent-type fluid on each side along the lateral chest wall and the preaxillary areas. This reduces bleeding when these areas are liposuctioned. Some of the tumescent-type fluid can be infiltrated around the base of the breast as well. If too much is used, the breast will become quite “wet” and cautery will be less effective.

Care must be taken to secure accurate hemostasis when using vasoconstrictors for breast reduction. It is especially important to look for and cauterize the perforators that come through the pectoralis fascia. They may remain constricted and not bleed during surgery, but these are usually the vessels that will later open up and cause a postoperative hematoma.

Creation of the Pedicle. The skin of the pedicle is de-epithelialized (Figure 56.4A). Putting the skin on tension by using either a commercial device or a lap pad held around the base of the breast with a Kocher clamp helps the assistant keep the skin taut. Care is taken to preserve the superficial veins that lie just beneath the dermis.

The pedicle is full thickness. It is incised directly down to the chest wall. Either a scalpel or a cutting cautery can be used. Care is taken not to expose pectoralis fascia to avoid bleeding and preserve the nerves that run just above the fascia. Some tissue cephalad can be left to leave a platform for the pedicle, but it is important not to try to push that tissue up in an attempt to increase upper pole fullness.

As with the inferior pedicle, the medial pedicle will be quite mobile and it is important that the assistant not pull excessively to avoid inadvertent undermining of the pedicle.

Parenchymal Resection. Both scalpel and cutting cautery can be used to remove breast tissue (Figures 56.4A and 56.5). The resection is beveled out laterally and medially. The inferior border of the medial pedicle becomes the medial pillar. The whole base of the pedicle rotates as the nipple and areola are inset into position and the pedicle itself gives an elegant curve to the lower pole of the breast.

The lateral resection will be more aggressive, but some tissue (about 2 cm thick) is left along the lateral vertical limb to fashion a lateral pillar. There is often a considerable excess of lateral breast tissue and direct excision is necessary because of its thick fibrous nature. Adipose tissue lateral to the breast (which is actually on the lateral chest wall) can be tailored with liposuction. Teenagers have very thick tissue laterally and this needs to be carefully carved out to prevent any ridges.

It is important to follow the preoperative plan for the amount of tissue to be resected. Because it can be difficult to resect an adequate amount of breast parenchyma with this technique, it may be tempting to remove tissue superiorly. If the patient has very little upper pole fullness, it is important not to resect superior tissue for a few centimeters on either side of the breast meridian. On the other hand, tissue can be removed superiorly when the patient has a significant amount of upper pole fullness.

FIGURE 56.4. Operative technique. A. Pedicle and skin resection pattern. B. Rotation of pedicle. Note that the inferior border of the medial pedicle is now the medial pillar. C. Closure of the pillars. The pillar length is only about 5 to 7 cm. The pillar closure starts about half way up the vertical opening because the parenchyma needs to be resected inferiorly as outlined (following the Wise pattern). D. Closure of the areola and skin. Originally, it was thought that this vertical incision needed to be shortened to allow the skin to retract. It has become increasingly evident that tightening the intracuticular suture not only interferes with healing but also delays resolution of the puckering.

FIGURE 56.5. Wise pattern inferior resection principle. A, B. The Wise pattern was adapted from a brassiere design and it is a good pattern to use for the parenchyma that is left behind—and not for what is removed. When the inferior wedge of tissue is removed and the pattern is closed, a pleasing breast with good projection is achieved. The Wise pattern is a better design for the parenchyma than it is for the skin. C, D. The principle of the Wise pattern as applied to breast reduction. Note that the tissue below the Wise pattern is the tissue that is removed. The vertical limbs of the skin resection pattern are not as wide as the pattern, but the tissue resection—both direct excision and liposuction tailoring—more closely follows the original pattern. E. The most important markings are noting the level of the upper breast border just below the preaxillary fullness and in this patient at the upper border of the striae (and therefore the new nipple position vertically about 10 cm below the upper breast border), the breast and chest wall meridian (and therefore the new nipple position horizontally) about 10 cm drawn straight from the chest meridian (not around the breast), as well as the areolar opening, the skin resection pattern, and the medial or superomedial (shown here) pedicle design.

Some tissue is left superolaterally to provide a platform to prevent inversion of the nipple–areolar complex. The pedicle may be full thickness but it will appear to be undermined (much as an inferior pedicle) and a small platform can help support the nipple and areola.

The inferior breast tissue below the Wise pattern is removed by direct excision and then liposuction is used to tailor the resection inferiorly, both laterally and medially. Liposuction is not used for volume reduction, but it is used to correct asymmetry that remains during closure and it is used for cosmetic refinement.

The skin flaps remain attached to the breast tissue superiorly and laterally, as well as superiorly and medially. The resection is beveled out laterally and medially and then finished with liposuction. The resection is actually undermined inferiorly so that the inferior breast can now become chest wall skin (and fat) as the IMF rises. The fold will only rise about 1 to 2 cm at the meridian, but it will curve up considerably as it extends laterally and medially.

The IMF is not a ligament but it is a criss-crossing condensation of fibers between the skin and the deep fascia. It is not a breast structure but a skin–fascial zone of adherence much like the gluteal fold. The fold fibers can be easily seen and some of them are removed when the surgeon wishes to make the IMF rise. The IMF fibers extend over a vertical distance of about 2 cm. The fibers can be safely removed in this procedure because the weight of the breast is left superiorly. If an implant is added, the surgeon should be careful to leave some of the IMF fibers intact.

The skin flaps are therefore full thickness superiorly with no undermining between the skin and the breast tissue. The lateral flap is beveled out laterally to remove any excess parenchyma. Inferiorly, the tissue is thinned (with still a layer of fat to prevent adhesions). Flap thickness is thinnest at the skin margins (about 2 cm) and it gets thicker as one extends laterally and medially. The pillars should be about 2 cm thick and have a vertical distance of about 7 cm. There will be an excess of skin remaining inferiorly compared with breast parenchyma. The inferior skin below the Wise pattern should have a thickness of about 1 cm. Fat is needed on the dermis to prevent adherence and scar contracture.

Insetting the Pedicle. It is easier to inset the pedicle after the base of the areola is closed (Figure 56.4B). A single 3-0 polydioxanone suture (PDS) or Monocryl suture is used. Some dermis is incorporated with the first bite at the base of the pedicle, but the dermis itself does not need to be undermined. Once this suture is tied, the nipple and areola rotate easily into position. The amount of rotation will vary—only enough rotation is needed to allow a comfortable inset with minimal compression.

Even though the pedicle is carried full thickness down to the chest meridian, it is very mobile and may appear to have been undermined.

The medial and lateral pillars are then closed. Final inset and closure of the areola is performed later.

Closure of the Pillars. The inferior border of the medial pedicle now becomes the medial pillar (Figure 56.4C). The pedicle needs to be pulled up so that the first pillar suture is placed just next to the inferior aspect of the base of the pedicle. Closure of the pillars starts about half way up the skin openingnot at the bottom of the skin resection pattern and not at the IMF.

The sutures do not need to be deep. Some lateral pillar tissue at the same level on the other side is also incorporated into this first suture. There is no need to take large bites or to include fatty tissue. It is important to place the suture on either side into fibrous tissue. There is some fibrous tissue in even the fattiest breasts. The pillars should come together without tension.

Only a few sutures are needed and it is important to pull up on the pedicle as each suture is placed so that the inferior border of the medial pedicle is positioned as the medial pillar. If the pedicle is long and heavy, it may be wise to suture some of the pedicle up onto the chest wall to help prevent bottoming-out.

Closure of the Dermis. The dermis is closed so that the resultant incision line is vertical (Figure 56.4D). Deep buried 3-0 Monocryl sutures are ideal because they absorb relatively quickly and they are less likely to extrude than PDSs. There is no need to suture the dermis up onto the breast parenchyma (it will delay shape resolution postoperatively). Only enough sutures are used to maintain approximation of the margins.

Liposuction. Before final closure of the skin, it is a good idea to stand back and assess asymmetry and shape. The surgeon should be able to visualize the Wise pattern and leave that behind—with no tension on the pillars and no tension on the skin. Tissue beyond the Wise pattern needs to be removed by direct excision complemented by liposuction. Some surgeons prefer to sit the patient up at this stage.

Unless the patient has very thick fibrous breast tissue (which occurs in many of the normal-weight teenagers) liposuction can be used to correct asymmetry.

The area that needs to be carefully checked is the area just above the existing IMF. There should be no excess subcutaneous tissue remaining that will result later in a pucker. The tissue inferiorly at the level of the meridian will often need direct excision (there are definite transverse fibers at the level of the fold), especially if the surgeon wishes the fold to rise. Liposuction can be used medially and (especially) laterally to tailor this region.

Liposuction is also used to reduce excess fat along the lateral chest wall and in the preaxillary areas. If the patient is obese, then tumescent-type infiltration is recommended for the areas to be suctioned. Patients are warned preoperatively that these areas will bruise and that they are often the source of more discomfort postoperatively than the breasts themselves.

Closure of the Skin. The vertical skin closure is best achieved by a running subcuticular 3-0 or 4-0 Monocryl suture. It is important to close this skin relatively loosely. Extra skin does not need to be excised in a lateral or medial direction to hold the shape of the breast. Deep bites, tight sutures, and skin tension will only delay wound healing.

The skin closure should not be gathered. It was originally thought that the skin should be gathered to shorten the length of the vertical scar. Not only does this skin stretch out (or it remains pleated requiring revision), it is actually important to realize that a short vertical distance (which may be needed when the skin is used as a brassiere) tends to flatten and compress the breast. A well-shaped “B” cup breast has a vertical distance from the bottom of the areola to the IMF of 7 cm. A well-shaped “C” cup breast has a vertical distance of 9 cm and a “D” cup has a vertical distance of 11 cm.

In fact, excess skin gathering will actually delay resolution of any skin puckering inferiorly. Good quality skin will adapt very well to the new breast shape. With the procedure described in this chapter, the breast shape relies on the parenchyma left behind (without any tension) and not on the skin brassiere.

It may be tempting to close the skin as an “L” or a “J” or even a “T,” but this is usually not necessary. When there is a large amount of loose, inelastic skin (such as found in a post-bariatric patient) excision may be indicated. On the other hand, this is rarely needed in most breast reductions up to 1,000 or more grams. It is not the amount of the parenchymal resection that is important, but the quality of the redundant skin that will make this determination.

It is important not to suture the skin up onto the breast parenchyma. This maneuver will only delay resolution. It is also important not to suture the “pucker” at the lower end of the vertical skin down to the chest wall. If it actually remains adherent, it will lead to an indentation that will later need to be corrected.

The excess skin that remains inferiorly adapts surprisingly well to the new breast shape. It is difficult for surgeons who have been trained to keep the vertical skin length at 5 cm to accept a long (sometimes more than 12 cm) vertical skin opening. The temptation to excise this extra skin can be difficult to resist.

Closure of the Areola. The skin opening for the areola should be round. In the past, when the vertical skin was gathered significantly, a teardrop shape resulted. This could take several months to settle postoperatively. Now that gathering is not recommended, the problem of distortion of the areola is no longer a concern.

Because the upper breast border does not change postoperatively, it is not a good idea to change the nipple position as marked preoperatively. The areolar skin opening can be trimmed if needed to make sure that the opening is circular.

The skin opening will determine the final areolar diameter. Areolar skin stretches more than breast skin and it will stretch out to fit the skin opening. A 16 cm skin opening circumference will result in a 5 cm diameter areola. A 14 cm skin opening circumference will result in a 4.5 cm diameter areola.

If there is a considerable discrepancy between the circumference of the skin opening and the circumference of the areola (when it is stretched out properly), then consideration should be given to a permanent type of suture to prevent widening. Usually, however, a few centimeter discrepancy is easily tolerated and closure is best achieved by a few interrupted 3-0 or 4-0 Monocryl sutures followed by a running subcuticular suture.

A true “circumvertical” pattern requires a permanent suture in an attempt to prevent areolar widening. The author believes that it is better to match the areolar and skin circumferences and extend the length of the vertical scar. Surgeons find it difficult to realize that a longer vertical scar is not only acceptableit is required to allow for the increased projection that is achieved with this approach.

Drains and Antibiotics. The use of both drains and antibiotics is controversial. Drains do not prevent a hematoma, but they may reduce the substrate for bacteria. When drains are used postoperatively, they are usually removed on the following day, but some surgeons will leave them in place for several days. Many surgeons do not use drains at all unless there is considerable oozing present (as can occur when patients ignore advice to stop anti-inflammatory medications for 2 weeks preoperatively). Drains can be brought out through the vertical incision or through a separate stab incision.

Seromas do occur but they are usually allowed to settle on their own. Drains would need to be used for many days or even weeks to prevent a seroma from collecting. The author’s preference is not to use drains at all and seromas are not aspirated but allowed to resorb on their own.

Cephalosporins are the most commonly used antibiotics. There is controversy over whether they should be used at all, whether they should be used only perioperatively, or whether they should be used for several days postoperatively. Breasts are not completely “clean” and breast ducts do harbor bacteria such as Staphylococcus epidermidis.

The author found that antibiotics were integral to preventing suture spitting. With the current recommendation of using only one preoperative antibiotic dose, the author has been able to reduce suture spitting by using Monocryl Plus which has an antibacterial (triclosan) incorporated into the suture.

Representative cases are shown in Figures 56.6–56.8.

Postoperative Course. Steristrips or Micropore paper tape is applied to the incisions. The author prefers paper tape and it can be left in place for about 3 weeks. A few horizontal strips can be applied inferiorly to help encourage the redundant inferior skin to contract. Taping of the whole breast is not necessary. The patient can shower the day after surgery, wash over the tape, and then pat it dry. A brassiere is not used for compression, but can be used to hold gauze bandages (initially) and pantyliners (after a couple of days) in place.

Patients are encouraged to gradually increase their activities. Return to desk work may only take 1 to 2 weeks, whereas return to heavy physical activity may take several weeks. The pucker (dog-ear at the inferior end of the vertical incision) may take several weeks and months to settle. A seroma may occur which makes the pucker look more ominous, but seromas will settle relatively quickly without intervention.

Patients should be warned about the time it takes for resolution of the shape, any asymmetries, or persistent puckers. Surgeons are often concerned about the length of time for this type of breast reduction to settle, but the postoperative course is very similar to an inverted-T, inferior pedicle. The postoperative discomfort is actually less and the shape at the end of the procedure does not need to look concave inferiorly. Patients have an acceptable shape within the first few weeks after surgery.

They should know that revisions may be necessary in a limited number of patients, but that a full year should pass before considering any corrective surgery.

Complications

Complication rates reported in the literature can be confusing. Care must be taken when comparing complications to determine whether these are “major” or “minor.” Revision rates will also depend less on the procedure and more on the threshold of a particular surgeon to perform a revision. All procedures in plastic surgery have a certain revision rate. An inferior skin pucker is often more easily corrected than a medial or lateral breast pucker.

Hematoma. Hematomas may develop postoperatively if transected vessels are not apparent because they are constricted by epinephrine used for infiltration. The surgeon must be aware of this problem and take care to search out such vessels and cauterize them. Drains will not prevent hematomas and any significant hematoma will require re-operation.

Seromas. Seromas can occur with or without the use of drains. Even leaving the drains in for several days does not prevent the development of seromas. Aspiration may be indicated, but the seromas will tend to recur. They can be left to resolve on their own. Although surgeons may be concerned that a pseudobursa may develop, this does not appear to be a problem.

Nipple–Areolar Necrosis. Breast reduction surgery is also a blood supply–reducing operation. Care must be taken while creating the pedicle to preserve as much blood supply as possible. Although a clear understanding of anatomy is important, the actual blood supply in any particular patient is guesswork at best.

Nipple necrosis may be one of the best kept “secrets” in plastic surgery but surgeons (and patients) should be aware that nipple necrosis is less likely to be a result of surgeon error than it is a pattern of blood supply that cannot be determined preoperatively. The incidence of nipple necrosis may be as high as 0.5% in all types of pedicles and skin resection patterns.

Although it has been advised to take a nipple and areola that is compromised and convert it to a free nipple graft, this decision is extremely difficult. It is not uncommon for areolas to look dusky and pale at the end of the procedure. Most surgeons are well aware that recovery is the rule. It would be inappropriate to convert these areolas to free grafts because grafting results in a lack of sensitivity and a lack of nipple projection. Breast feeding is not possible and grafts can heal with irregular pigmentation.

FIGURE 56.6. A 34-year-old 185 lb, 5′7″ patient who wore a 36F brassiere. A. Preoperative frontal view moderate sized breast reduction. B. Preoperative lateral view. C. Preoperative view with markings. The upper breast border is not marked but is at the upper level of the striae. A purely medial pedicle is marked on this patient (many of these measurements are performed for statistical analysis only). D. Intraoperative view at completion of the vertical approach using the medial pedicle. The patient had 625 g of tissue removed from the right breast and 720 g from the left breast. She also had 400 cc of fat removed from the lateral chest wall and preaxillary areas with some contouring of the lower portion of the breasts. Surgery time was 90 minutes. I now gather this incision far less than shown in this photograph.E. Frontal view at 10 days post-op. F. Lateral view at 10 days post-op. G. Arms up view at 10 days. The results do not necessarily take a long time to settle postoperatively. H. Frontal view at 15 months postoperatively. I. Lateral view at 15 months postoperatively. J. Arms up view at 15 months postoperatively.

FIGURE 56.7. A 60-year-old patient who was 5′4″ tall, weighed 195 lb and wore a 38DD brassiere. She had 680 g of tissue removed from each breast. A. Frontal preoperatively. B. Lateral preoperatively. C. Frontal 10 days postoperatively. D. Lateral 10 days postoperatively. E. Frontal 4.5 years postoperatively. F. Lateral 4.5 years postoperatively.

FIGURE 56.8. A 24-year-old woman who had 295 g of tissue removed from her right breast and 315 g from her left breast. A. Frontal preoperatively. B. Lateral preoperatively. C. Frontal markings preoperatively. D. Frontal 10 days postoperatively. E. Lateral 10 days postoperatively. F. Frontal arms elevated 10 days postoperatively. This view is humbling in that it shows any residual puckering or deformity. G. Frontal 18 months postoperatively. H. Lateral 18 months postoperatively. I. Frontal arms elevated 18 months postoperatively.

If it is clear that a nipple and areola are suffering from venous congestion postoperatively, then measures such as removing sutures or taking the patient back to the operating room for exploration may help. Many patients are now discharged on the same day as surgery and the opportunity for this type of evaluation is not available. It would make sense to keep patients for observation if this evaluation was clear-cut, but it is not. Necrosis is most likely a lack of arterial input and this cannot be corrected. Necrosis from correctable venous congestion is much less likely. The risk to benefit ratio is such that it is probably best to allow almost all questionable cases to declare themselves without intervention. Blistering and some loss may occur, but this is often preferable to active intervention—which carries its own risks.

Rarely, complete loss of the nipple and areola will occur. Intervening on the questionable cases is not likely to decrease this incidence. Each patient will need to be evaluated over time as to whether the necrotic tissue should be allowed to heal by secondary intention, in-office debridement, or intraoperative debridement. Some form of nipple and areolar reconstruction is then considered.

Infection. Many surgeons believe that antibiotics are indicated because the breast ducts are open to the external environment. Some surgeons use no antibiotics, some use perioperative antibiotics, and some surgeons use a full course of antibiotics. The most commonly used antibiotics are first- or second-generation cephalosporins.

The author initially did not use any antibiotics with breast reduction surgery, but unfortunately, some patients developed infections. A full course (a week) of cephalosporins reduced these infections. Interestingly, the problem of suture “spitting” also disappeared. When only one preoperative dose of antibiotics was later used, some suture spitting recurred. The best approach in the author’s practice has been to use the one preoperative dose combined with an antibacterial (not antibiotic) impregnated suture. This has reduced the infection rate and controlled suture spitting while reducing the incidence of postoperative diarrhea.

Wound Healing. All types of breast reduction have problems with wound healing. The inverted-“T” has more problems with necrosis at the “T” and the vertical types can have more problems on the vertical incision line. Wound healing problems can be prevented to a significant degree by avoiding undue tension on the incision lines. Avoiding tension can be harder with the inverted-“T” because the procedure relies more on the skin to hold the shape. The vertical approaches are more likely to run into problems if the surgeon causes constriction during closure by excising too much skin or by undue skin gathering. Antibiotics may be helpful in reducing wound healing problems.

It is important to avoid tension on both the parenchymal and the skin closure.

Extensive flap necrosis is rare. It is more likely to occur when the skin is undermined and when excessive tension is applied to the flaps during closure. Debridement may be necessary. Skin grafting may close the wounds earlier, but the cosmetic result is often better if the open areas are allowed to heal secondarily.

Under–resection. It is far more difficult to remove enough breast tissue with the vertical techniques than it is with the inverted-“T” techniques. At the end of the procedure, the breasts actually look smaller than they are. This can be a problem for surgeons who have been accustomed to assessing size with the inverted-“T.” The extra projection can be misleading. It is important to determine the amount of breast tissue to be removed preoperatively and to then follow that plan.

The excess breast tissue should be removed laterally from under the lateral flap. Excess superior breast tissue should only be removed when a patient has an overly full upper pole preoperatively. All excess tissue below the Wise pattern should also be removed. Any attempt to pull in lateral tissue or push up inferior tissue will fail. Excess tissue that has been pulled into a new location will revert to its original position. It is important to remove the excess and then close the parenchyma (and the skin) without tension. The surgeon should leave the Wise pattern of parenchyma behind and then remove any excess tissue peripheral to that pattern.

At least 6 to 12 months should elapse before undertaking any re-reduction. This can be achieved through liposuction-only or by re-reducing tissue in the vertical plane. Most of the re-reduction will involve parenchyma. It is important not to take too much skin in the re-reduction or a torpedo-type shape will result. An inferior wedge resection combined with further excision under the lateral flap will be needed. Fortunately, the shape will settle because the skin will inevitably stretch to some degree.

Asymmetry. Correction of asymmetry should follow similar guidelines to re-reduction. The problem may be solved by liposuction-only or it may require parenchymal excision, scar release, and shaping. Breasts can be asymmetrical in size and shape (and IMF location) preoperatively and the surgeon can better assess this asymmetry by having the patient raise her arms above her head.

Puckers. The vertical skin pattern approach involves excision of skin and parenchyma in a vertical ellipse. This means that there are two dog-ears—one that is chased into the areolar opening and disappears and one that is chased inferiorly. The skin excision should remain as a “U” and not be tapered into a “V,” especially if this would mean that the scar would extend below the IMF. The excess skin will tuck in under the breast as it settles. If a “V” is used, it is important to remove enough of the underlying subcutaneous tissue on each side to prevent a pucker.

It is advisable to wait a full year before performing any revisions. At first glance, the pucker that remains may appear to be a problem of excess skin. But usually the real problem is excess subcutaneous tissue between the original and the new IMF. If the pucker lies above the new IMF, it can be corrected with a vertical skin excision complemented by a horizontal fat resection as needed. If the pucker lies below the new IMF it will require a horizontal excision but the horizontal excision will need to be designed to curve upward and will need to be long enough to prevent the creation of two new dog-ears.

Adding a “T” at the initial procedure may obviate the necessity to revise any puckers, but it has been shown that performing a “T” resection did not alter the revision rate. Fortunately, many of these revisions can be performed in the office under local anesthesia. The need for occasional revisions is an integral part of plastic surgery, and breast reduction is no exception. Revisions do tend to be more common with the vertical approaches, especially during the learning curve. Each surgeon will have a different threshold for revision, but a rate of about 5% is not unexpected.

SUMMARY

It has been repeatedly documented that both physical and psychological outcomes are excellent after breast reduction surgery. The challenge is to minimize scarring at the same time as giving the breast an aesthetically pleasing and enduring shape.

The vertical approaches are excellent for the small- to medium-sized reductions. With experience, surgeons also find that the methods are applicable to larger and larger reductions. There is no question that there is an initial learning curve (as there is with the inverted-“T”), but surgeons eventually feel rewarded not only by the improved scarring that results but also by the improved shape. The procedure takes less time to perform; there is less blood loss and a faster patient recovery time compared with inverted-“T” techniques.

The concepts in the vertical techniques involve far more than just a different vector in the skin and parenchymal resection patterns. This vector plus the more superiorly based pedicles give a shape that resists gravity over time. In general, the vertical approaches use the breast parenchyma to shape the skin, whereas the inverted-“T” approaches use the skin to shape the breast.

Suggested Readings

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Hall-Findlay EJ. Aesthetic Breast Surgery. St Louis, MO: Quality Medical Publishing; 2010.

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