Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes

Principle and Logic of Vertical Reduction Repair Double-Ring Breast Reduction

BACKGROUND

Secondary reduction mammaplasty poses challenges.

OBJECTIVES

This article delves into the reasons and complaints regarding secondary repair following double-ring method and outlines the principle and logic of utilizing vertical incision for repair.

METHODS

A retrospective analysis of patients who underwent secondary reduction mammaplasty in our hospital was conducted. The analysis included baseline demographic data, reasons for consultation, surgical records, and postoperative outcomes.

RESULTS

Thirty-five patients (70 breasts) underwent secondary reduction mammaplasty. The mean time between the primary reduction mammaplasty and second procedure was 2.99 years (range, 0.5-15years). The mean weights were 210.49g (range, 42-558g) and 207.91g (range, 6-560g) for left and right mastectomies, respectively. Reasons for secondary reduction mammaplasty include poor shape (flat breasts and pseudoptosis), widened incision scar, persistent macromastia, and bilateral asymmetry.

CONCLUSIONS

The superior and superomedial vertical techniques are safe, effective, and satisfactory in secondary reduction mammaplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Effect of pedicle type on breast reduction: Clinical and patient-reported outcomes

PURPOSE

The choice of pedicle in reduction mammaplasty is highly variable with prior studies demonstrating high patient satisfaction in most cases. This study aimed to examine the impact of pedicle type on clinical and patient-reported outcomes in patients undergoing reduction mammaplasty.

METHODS

A total of 588 patients underwent bilateral reduction mammaplasty with Wise pattern or modified Robertson incision by 13 surgeons at a single institution. Clinical outcomes were compared according to the pedicle type in all patients and BREAST-Q responders (32% response rate). Survey respondents were sub-grouped by resection volume, and the BREAST-Q satisfaction scores were compared.

RESULTS

Among all included reduction mammoplasties, 439 (75%) were performed using inferior pedicles, and 149 (25%) using superior or superomedial pedicles. Responders and non-responders were similar in preoperative characteristics including age, body measurements, and comorbidities. Although a higher incidence of infection occurred among the responders, clinical outcomes were comparable across all pedicle types. A total of 187 patients completed the BREAST-Q. Compared to the superior pedicle group, respondents in the inferior pedicle group reported higher nipple satisfaction, even when adjusted for resection weight over 500 g. In contrast, the superior pedicle group had better sexual well-being scores, which persisted in resection weight less than 500 g (all p values <0.05).

CONCLUSION

Inferior pedicles were associated with greater nipple satisfaction and superior pedicles were associated with greater sexual satisfaction. Our findings suggest that those with resections less than 500 g were more satisfied with superior pedicles whereas those with greater resections were more satisfied with inferior pedicles.

Pedicle Selection and Design in Reduction Mammaplasty: The Role of Preoperative Fluorescence Imaging

BACKGROUND

Breast reduction has a wide selection of pedicles but often relies on the surgeon's preference and experience. Necrosis of the nipple-areola complex (NAC) is a catastrophic complication of breast reduction surgery.

OBJECTIVES

To solve the above problem objectively, we applied fluorescence imaging technology to the pedicle selection and design of breast reduction surgery for the first time, so that the dominant vessels of the NAC were included in the designed pedicle.

METHODS

We retrospectively enrolled 120 patients with breast reduction (a total of 239 breasts). We compared 60 patients who underwent breast reduction without fluorescence imaging for pedicle selection (Group A) with 60 patients who underwent pedicle selection with fluorescence imaging (Group B). The NAC blood supply was monitored after the operation.

RESULTS

In this study, 60 Group A cases (119 breasts) and 60 Group B cases (120 breasts) were analyzed. There were no statistically significant differences in patient demographic data or intraoperative resection weights. There were 7 cases of NAC necrosis in Group A (1 case of complete necrosis and 6 cases of partial necrosis), while no NAC necrosis occurred in Group B. There was a significant difference in the rate of NAC necrosis between the 2 groups.

CONCLUSIONS

Preoperative fluorescence imaging can guide the selection and design of breast reduction, significantly reducing postoperative NAC blood supply obstacles and necrosis.

LEVEL OF EVIDENCE: 3

The Underused Superomedial Pedicle Reduction Mammaplasty: Safe and Effective Outcomes

BACKGROUND

The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial pedicle technique in a large series.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. All consecutive superomedial pedicle reduction mammaplasty cases for benign symptomatic macromastia were included.

RESULTS

A total of 462 breasts were analyzed. Mean age was 38.3 ± 13.38 years, mean body mass index was 28.5 ± 4.95, and mean reduction weight was 644.4 ± 299.16 g. Regarding surgical technique, a superomedial pedicle was used in all cases; Wise-pattern incision was used in 81.4%, and short-scar incision was used in 18.6%. The mean sternal notch-to-nipple measurement was 31.2 ± 4.54 cm. There was a 19.7% rate of any complication, the majority of which were minor in nature, including any wound healing complications treated with local wound care (7.5%) and scarring with intervention in the office (8.6%). There was no statistically significant difference in breast reduction complications and outcomes using the superomedial pedicle, regardless of sternal notch-to-nipple distance. Body mass index ( P = 0.029) and breast reduction specimen operative weight ( P = 0.004) were the only significant risk factors for a surgical complication, and with each additional gram of reduction weight, the odds of a surgical complication increased by 1.001. Mean follow-up time was 40.5 ± 7.1 months.

CONCLUSION

The superomedial pedicle is an excellent option for reduction mammaplasty, portending a favorable complication profile and long-term outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Analysis of Incidentally Found Proliferative Lesions in Oncoplastic and Macromastia Breast Reductions

BACKGROUND

Reduction mammaplasty pathologic specimens can reveal incidentally found proliferative lesions. However, there is a lack of data investigating the comparative incidences and risk factors for such lesions.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single large academic medical institution in a metropolitan city by two plastic surgeons over a 2-year period. All reduction mammaplasties, symmetrizing reductions, and oncoplastic reductions performed were included. There were no exclusion criteria.

RESULTS

A total of 632 breasts were analyzed-502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions-in 342 patients. Mean age was 43.9 ± 15.9 years, mean body mass index was 29.2 ± 5.7 kg/m 2 , and mean reduction weight was 610.0 ± 313.1 g. Patients who underwent reduction mammaplasty for benign macromastia had a significantly lower incidence (3.6%) of incidentally found breast cancers and proliferative lesions compared with patients with oncoplastic reductions (13.3%) and symmetrizing reductions (17.6%) ( P < 0.001). On univariate analysis, personal history of breast cancer ( P < 0.001), first-degree family history of breast cancer ( P = 0.008), age ( P < 0.001), and tobacco use ( P = 0.033) were all statistically significant risk factors. Using a backward elimination stepwise reduced multivariable logistic regression model for risk factors associated with breast cancer or proliferative lesions, age ( P < 0.001) was the only retained significant risk factor.

CONCLUSIONS

Proliferative lesions and carcinomas of the breast found in reduction mammaplasty pathologic specimens may be more common than previously reported. The incidence of newly found proliferative lesions was significantly lower in cases of benign macromastia compared with oncoplastic and symmetrizing reductions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

A Comparison of Complication Rates in Wise Pattern Versus Vertical Breast Reduction

BACKGROUND

Breast reduction has a well-chronicled history and remains a common reason for patients to seek plastic surgery consultation. The Wise pattern is the most common skin reduction pattern in the United States. Vertical pattern reduction is also widely used and offers the potential for decreased scar burden. Both patterns have been used with a variety of pedicles for preservation of the nipple areolar complex, which may also impact complication rate and patient satisfaction. There is a preponderance of literature on breast reduction surgery but limited comparative data on the safety profile of these patterns. The purpose of this article is to review the comparative literature, with emphasis on the overall risk of complications.

METHODS

OVID and PubMed were used to query the literature for articles comparing complication rates in both Wise pattern and vertical breast reduction. Inclusion criteria were case series that encompassed both vertical and Wise pattern reductions and cited the rate of complications. Complications included in our analysis of total complication rate were as follows: hematoma, seroma, infection, dehiscence, fat necrosis, skin necrosis, and nipple areolar complex necrosis. We excluded standing cutaneous deformity as a complication. Articles that included oncoplastic breast reductions were also excluded. The primary analysis was an inverse variance-weighted random-effect meta-analysis of overall complication rate, with the association between the technique and overall complication rate quantified using odds ratios.

RESULTS

Eight articles were identified that met inclusion criteria, representing 963 patients (525 Wise pattern and 438 vertical pattern). The overall complication rate pooled across the studies favored vertical pattern reduction, but the result was not definitive.

CONCLUSIONS

Vertical pattern breast reduction can be done safely. Our statistical analysis found a trend toward decreased complications with vertical reductions, but did not reach statistical significance. Patients seeking breast reduction are a heterogeneous population with respect to breast size, degree of ptosis, body habitus, body mass index, comorbidities, and acceptance of scars. It remains important to individualize the approach to the patient and their needs. More quantitative, comparative data, especially from randomized controlled trials, would be useful to further evaluate the relative safety profiles of the 2 patterns.

Efficacy of Tranexamic Acid in Reducing Seroma and Hematoma Formation Following Reduction Mammaplasty

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery.

OBJECTIVES

The aim of this study was to investigate the value and safety profile of both intravenous and topically administered TXA in the setting of bilateral reduction mammaplasty.

METHODS

A retrospective review was performed to identify consecutive patients who underwent bilateral reduction mammaplasty for symptomatic macromastia (January 2016-July 2021). Pertinent preoperative, intraoperative, and postoperative details were collected/reviewed. Primary outcome measures included hematoma requiring surgical evacuation and clinically significant/symptomatic seroma formation mandating percutaneous aspiration. Patients taking anticoagulation/antiplatelet medication or those with a history of thromboembolic diseases were excluded. Patients who had received TXA were compared to a historical control group who did not receive TXA within the same consecutive cohort.

RESULTS

A total of 385 consecutive patients (770 breasts) were included. TXA was used in 514 (66.8%) cases (topical, 318 [61.9%]; intravenous, 170 [33.1%]; intravenous and topical, 26 [5.1%]). Neither seroma nor hematoma were impacted/reduced with TXA (P > 0.05). Increased age (hazards ratio, 1.06 per 1-year increase; 95% CI, 1.004-1.118) significantly increased the risk of hematoma (P = 0.032). The use of drains significantly decreased the risk of seroma (P < 0.0001). Increased BMI increased the risk of seroma (hazards ratio, 1.16 per 1-kg/m2 increase; 95% CI, 1.06-1.26; P = 0.0013). The use of TXA did not impact drain duration.

CONCLUSIONS

This study, the largest to date on the use of IV and topical TXA, did not find any reduction in risk when using TXA in breast reduction surgery.

LEVEL OF EVIDENCE: 3

A Simplified Approach to Breast Reduction Using the Medial Pedicle

Background

Breast reduction is a common procedure for plastic surgery. We have adopted a modified technique using the medial pedicle, with markings using a 15-9-9 framework and a methodical step wise approach.

Objectives

This study introduces the 15-9-9 framework as a design for medial pedicle breast reductions that is easy to perform and teach, with favourable outcomes.

Methods

Markings using the 15-9-9 framework was used, describing the mosque dome and medial pedicle length and width. The technique was performed in day surgery under general anesthesia. Patients were followed up to 1 year, with photographs taken at each visit and complications recorded. A retrospective review of 80 patients between November 2013 and July 2019 was completed in a single surgeon’s practice.

Results

Patients were an average of 49 years (18-72 years) with a BMI of 28 (23-32). The average postoperative sternal notch to areola distance was 22 cm (19-26 cm) and sternal notch to nipple distance was 24 cm (21-28). The average duration of the surgical procedure was 3.4 hours. An average of 464 g (90-1210 g) was removed from each breast. Complication rates were low with minor fat necrosis (14%), T junction breakdown (10%), hematoma (3.8%), dog ear formation (3.8%), junctional necrosis (2.5%), and partial nipple loss (1.3%). One patient had a cerebrovascular accident in the late postoperative period. Aesthetically pleasing results were achieved postoperatively.

Conclusions

This technique using the 15-9-9 framework is simple to learn, perform and teach with overall aesthetically pleasing outcomes.

Dealing with the Displaced Nipple–Areola Complex in Macromastia Using a Superomedial Pedicle and Inverted T Pattern

In macromastia, especially in patients with a raised BMI, the nipple areola complex (NAC) may be displaced from the breast midline/meridian. This is poorly documented, and there is little published on surgical management. The aim of the study was to identify the incidence of displaced NAC in macromastia and discuss the management using the superomedial pedicle, by canting the vertical limbs of the inverted T/keyhole. The study also aimed to postulate a theory of pathogenesis.