Breast reduction
Encyclopedia
Reduction mammoplasty is the plastic surgery procedure for correcting over-sized breasts
. In a breast reduction surgery for re-establishing a functional bust
that is proportionate to the woman’s body, the critical corrective consideration is the tissue viability
of the nipple-areola complex
(NAC), to ensure the functional sensitivity and lactational
capability of the breasts. The indications for breast reduction surgery are three-fold — physical, aesthetic
, and psychological — the restoration of the bust, of the woman’s self-image, and of her mental health
. In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to mastopexy (breast lift). Moreover, the correction of gynecomastia
(woman’s breast) is the analogous, enlarged male-breast reduction surgery procedure, wherein there is no consideration of lactation capability.
The woman afflicted with macromastia presents heavy, enlarged breasts (<500 gm per breast per the Shnur Scale) that sag and cause her chronic pains to the head, neck, shoulders, and back; an over-sized bust
also causes her secondary health problems, such as poor blood circulation
, impaired breathing
(inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassière-strap indentations to the shoulders; and the improper fit of clothes. In the woman afflicted with gigantomastia (<1,000 gm increase per breast), the average breast-volume reduction diminished her over-sized bust by three (3) brassière cup-sizes. The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations that a bodily-disproportionate bust imposes upon a woman; thereby it improves her physical and mental health
. Afterwards, the woman’s ability to comfortably perform physical activities previously impeded by over-sized breasts improves her emotional health (self-esteem
) by reducing anxiety
and lessening psychological depression
.
Medical history
The medical history records the woman’s age, the number of children she has borne, her breast-feeding
practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information, are her history of tobacco smoking
and concomitant diseases, breast-surgery and breast-disease histories, family history of breast cancer
, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness.
The physical examination records and establishes the accurate measures of the woman’s body mass index
, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of breast ptosis
, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the nipple-areola complex (NAC), and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight, kyphosis
(excessive, backwards curvature of the thoracic region
of the spinal column), skin irritation, and skin rash affecting the breast crease (IMF).
A woman develops large breasts usually during thelarche
(the pubertal breast-development stage), but large breasts can also develop postpartum, after gaining weight, at menopause
, and at any age. Whereas macromastia usually develops in consequence to the hypertrophy
(over-development) of adipose fat
, rather than to milk-gland hypertrophy. Moreover, many women are genetically
predisposed to developing large breasts, the size and weight of which often are increased either by pregnancy
or by weight gain, or by both conditions; there also exist iatrogenic
(physician-caused) conditions such as post–mastectomy
and post–lumpectomy
asymmetry. Nonetheless, it is statistically rare for a young woman to experience virginal mammary hypertrophy that results in massive, over-sized breasts, and recurrent breast hypertrophy
.
The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the over-development of the milk glands
or of the adipose tissue
, or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild (>300 gm) to the moderate (ca. 300–800 gm) to the severe (<800 gm). Macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging, breast ptosis
that is determined by the degree to which the nipple has descended below the inframammary fold (IMF).
Therapeutic approaches
Medical
Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy; yet a weight-reduction regimen for the over-weight woman can alleviate some of the excessive size and volume of her abnormally enlarged breasts. Physical therapy provides some relief for sufferers of neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chaffing, infection, and bleeding.
Surgical
Reduction mammoplasty, surgery or lipectomy, is the technically reliable method for diminishing the size and volume of the enlarged breast. The traditional, surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; yet it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar — around the nipple-areola complex (NAC), where the dark-to-light skin-color transition hides the surgical scar.
A reduction mammoplasty to re-size enlarged breasts and to correct breast ptosis
resects (cuts and removes) excess tissues (glandular
, adipose, skin
), over-stretched suspensory ligaments
, and transposes the nipple-areola complex (NAC) higher upon the breast hemisphere. At puberty
, the breast grows in consequence to the influences of the hormones
estrogen
and progesterone
; as a mammary gland
the breast is composed of lobules of glandular tissue, each of which is drained by a lactiferous duct
that empties to the nipple. Most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules — except during pregnancy
and lactation
, when breast milk constitutes most of the breast volume.
Composition
Surgically, the breast is an apocrine gland
overlaying the chest — attached at the nipple and suspended with ligaments from the chest — which is integral to the skin, the body integument
of the woman. The dimensions and weight of the breasts vary with her age and habitus (body build and physical constitution); hence small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750–1,000 gm. Anatomically, the breast topography
and the hemispheric locale of the nipple-areola complex (NAC) are particular to each woman; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (NAC to IMF).
Blood supply and innervation
The arterial blood
supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery
(from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries
. Drainage of venous blood
from the breast is by the superficial vein system under the dermis
, and by the deep vein system parallel to the artery system. The primary lymph
drainage system is the retromammary lymph plexus in the pectoral fascia
. Sensation in the breast is established by the peripheral nervous system innervation
of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerve
s, and thoracic spinal nerve 4
(T4 nerve) innervates and supplies sensation to the nipple-areola complex.
Mechanical structures of the breast
In realizing the breast-reduction corrections, the plastic surgeon takes anatomic
and histologic
account of the biomechanical
, load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (Poisson’s ratio of ∼0.5).
General
Reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a woman afflicted either with macromastia (<500 gm increase per breast) or with gigantomastia (<1,000 gm increase per breast). Breast reduction surgery has two (2) technical aspects: (i) the skin-incision pattern and the skin- and glandular-tissue excision technique applied for access to and removal of breast parenchyma
tissue. The incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars; (ii) the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of nerves and blood vessels (arterial
and venous
) that ensure its tissue viability
.
The specific reduction mammoplasty procedure is determined by the volume of breast tissues (glandular
, adipose
, skin
) to be resected (cut and removed) from each breast, and the degree of breast ptosis present: Pseudoptosis (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold); Grade I: Mild ptosis (the nipple is below the IMF, but above the lower pole of the breast); Grade II: Moderate ptosis (the nipple is below the IMF; yet some lower-pole breast tissue hangs lower than the nipple); Grade III: Severe ptosis (the nipple is far below the IMF; no breast tissue is below the nipple). The full, corrective outcome of the surgical re-establishment of a bodily-proportionate bust becomes evident at 6-months to 1-year post-opertaive, during which period the reduced and lifted breast tissues settle upon and into the chest. The post-operative convalescence is weeks long, depending upon the corrections performed; and some women might experience painful breast-enlargement during the first post-operative menstruation
.
Contraindications
Breast reduction surgery cannot be performed if the woman is lactating
, or has recently ceased lactating; if her breasts contain unevaluated tissue masses
, or unidentified microcalcifications; if she is suffering a systemic illness; if she is unable to understand the technical limitations of the plastic surgery; and her inability to accept the possible medical complications
of the procedure.
I. Inferior pedicle technique (Anchor pattern, inverted-T incision, Wise pattern)
The inferior pedicle (central mound) features a blood vessel supply (arterial and venous) for the nipple-areola complex (NAC) from an inferior, centrally-based attachment to the chest wall. The skin pedicle maintains the innervation and vascular
viability of the NAC, which produces a reduced, sensitive breast with full lactational
capability and function. The volume and size reduction of hypertrophied breasts
is performed with a periareolar incision to the nipple-areola complex, which then extends downwards, following the natural curve of the breast hemisphere. After cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the nipple-areola complex is transposed higher upon the breast hemisphere; thereby the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the woman’s person. Nonetheless, breast-reduction with an inferior pedicle, occasionally produces breasts that appear squared; yet, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia.
II. Vertical scar technique (lollipop incision)
The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision scars
and a nipple-areola complex (NAC) elevated by means of a pedicle (superior, medial, lateral) that maintains the biologic
and functional
viability of the NAC. The increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the NAC . The vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars.
III. Horizontal scar technique
The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a nipple-areola complex (NAC) pedicle. To elevate the NAC, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the Anchor pattern). The horizontal-scar technique best applies to the woman whose over-sized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed NAC. The potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold.
IV. Free nipple-graft technique
The breast reduction performed with the free nipple-graft technique transposes the nipple-areola complex (NAC) as a tissue
graft without a blood supply, without a skin and glandular pedicle. The therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. The therapeutic disadvantage is a breast without a sensitive nipple-areola complex, and without lactational
capability. The medically indicated candidates are: the woman whose health presents a high risk of ischemia
(localized) tissue
anemia
) of the nipple-areola complex
, which might cause tissue necrosis
; the diabetic woman; the woman who is a tobacco smoker
; the woman whose over-sized breasts have an approximate NAC-to-IMF measure of 20 cm; and the woman who has macromastia requires much resecting of the breast tissues.
V. Liposuction-only technique (lipectomy)
The breast reduction performed with the liposuction-only
technique usually applies to the woman whose over-sized breasts require the removal of a medium volume of internal tissue; and to the woman whose health precludes her being under the extended anaesthesia usual to surgical breast-reduction operations. The ideal lipectomy candidate is the woman whose low-density breasts are principally composed of adipose tissue
, have a relatively elastic skin envelope, and manifest mild ptosis
. The therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior, hence, a shorter post-operative healing period for the incision scars; the therapeutic disadvantage is limited breast-reduction volumes.
with the Lejour technique applies a vertical-incision, a superior pedicle, breast liposuction
, and wide undermining of the skin of the lower portion of the breast. The technical efficacy of the Lejour breast reduction was established with the study Vertical Mammaplasty and Liposuction of the Breast (1994), which reported 153 reduction mammoplasties performed in 79 patients, wherein an average fat volume of 300 ml was removed from each breast, and the average resection of 480 gm of parenchymal tissue was removed from each breast.
Pre-operative matters
The medical treatment records
for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the over-sized breasts, the sternal-notch–to-nipple distances, and the nipple-to–inframammary-fold distances. The woman is instructed about the purposes of the breast reduction surgery, the achievable corrections, the expected final size, shape, and contour of the reduced breasts, the expected final appearance of the breast reduction scars
; possible changes in the sensation of the nipple-areola complex
(NAC), possible changes in her breast-feeding
capability, and possible medical complications
. The woman also is instructed about post-operative matters such as convalescence and the proper care of the surgical wounds to the breasts.
Incision-plan delineation — To the breasts of the standing patient, the plastic surgeon delineates the mosque dome skin-incision-plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (IMF), and the vertical axis of the breast, beneath the IMF. The upper-edge of the (future) nipple-areola complex (NAC) is marked slightly below the IMF-level, and a semicircle of 16-cm maximum diameter. In relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. The circumference of the (future) nipple-areola complex is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future NAC circumference; the incision-plan delineation continues down as a cone, and around the marked circumference.
Operative technique
The patient is laid supine upon the operating table so that the surgeon can later raise her to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. Afterwards, the pedicle epidermis surrounding the NAC (nipple-areola complex) is cut, and adipose tissue is liposuctioned from the breast. The medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. Then, the nipple-areola complex is transposed higher upon the breast hemisphere. The pillars of parenchymal tissue
are approximated (joined), and the skin envelope is sutured.
Notes
Post-operative matters
The woman is instructed to resume her normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassière; the convalescence regimen is for 3-months post-operative. She is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within 1–6 months post-operative; yet some cases might require surgical revision of the vertical scar. Scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications.
Complications
The post-operative complications occurred included seroma
, wound dehiscence
, hematoma
; whereas partial NAC necrosis
occurred in 10 per cent of the reduced breasts; yet, after refinement of the Lejour technique, the study Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases (1999), reported a reduced incidence rate of 7.0 per cent in the 324 breast reductions performed in 167 patients. Moreover, the incidence of such post-operative complications is greater among the women whose breasts required large-volume resection of the parenchyma
; in women who were obese
; in women who were tobacco smokers
; and in young women. Furthermore, wound dehiscence, epidermolysis, adipose tissue
necrosis, and infection
occur less among women who undergo Lejour-technique breast reduction, than among women who undergo a periareolar, Anchor pattern breast-reduction, or an inferior-pedicle breast reduction. Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 per cent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 per cent of the women; and total NAC insensitivity occurs in 1.0 per cent of women.
The reduction of over-sized breasts by liposuction only (lipectomy) is indicated when a minor-to-moderate volume-reduction is required, and there is no breast ptosis
to correct. Further indications for lipectomy are presented by: (i) the woman who requires a large-volume reduction, and wants un-scarred, sensate breasts, yet will accept a degree of ptosis; (ii) the woman who requires a secondary mammoplasty to correct an asymmetric breast, by up to one (1) brassière cup-size; and (iii) the girl afflicted with virginal breast hypertrophy
, as a temporary procedure performed before the conclusion of her thelarche
(the pubertal breast-growth phase), given the hypertrophy’s high rate of recurrence.
Contraindications
Breast reduction by liposuction only cannot be performed upon a woman whose mammogram indicates that the over-sized breast is principally composed of hypertrophied milk glands
. Furthermore, liposuction mammoplasty also is contraindicated for any woman whose mammograms indicate the presence of unevaluated neoplasms; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope.
Pre-operative matters
Consultation — The plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The woman is informed of the alternative, surgical
reduction techniques available for diminishing her over-sized breasts; of the consequent surgical scars
; of the possible loss of breast sensation; of the possible impairment of lactation
capability; and of the posible impairment of breast-feeding
functions. The woman is further informed of the possible medical complications, and is shown surgical photographic records of the average outcomes of breast-reduction surgery. The surgeon answers the woman’s questions to assist her in establishing realistic expectations (self-image) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the volume of her breasts, a secondary, surgical breast-reduction procedure can be performed later.
The measures of the bust — A liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the woman’s breasts, chest, and torso. Yet the measures of the bust are established in order to determine the required degree(s) of correction; thus, with the patient sitting erect, for each breast, the surgeon records the jugular-notch-to-nipple distances, the nipple-to-inframammary-fold distances, and any asymmetries. Afterwards, the anaesthetized patient is laid supine upon the operating table, with her arms laterally extended (abducted) in order to fully expose the breasts.
Anaesthestic preparation — To limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast’s circulatory system is established with an anaesthetic solution (lidocaine
+ epinephrine
in saline solution) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforation cannula
, the anaesthetic infiltration begins at the deep plane of the breast, and continues as the cannula is withdrawn towards the superficial plane of the breast. The entire area of the breast is infiltrated with the anaesthetic solution until the tissues become tumescent (firm). Moreover, as required by the patient’s physique, an intravenous (IV) pressure bag can be applied to hasten the infiltration; after the anaesthetic has numbed the breast, the plastic surgeon begins the lipectomy breast-reduction.
Operative technique
The surgeon effects a stab incision just above the lateral aspect of the inframammary fold (IMF), piercing the skin 2-cm above the inframammary fold, in the midline. The pre-tunnelling is performed with the blunt-tip, multi-perforation cannula used to infiltrate the anaesthetic solution to the breast tissues. A blunt-tip, 4-mm cannula, connected either to a medical-grade vacuum pump or to a syringe, is used to aspirate (suck) the adipose fat
. The cannula is maneuvered laterally (in fanning movements), beginning in the deep plane of the breast and concluding in the superficial plane of the breast; the adipose fat
sucked from the breast is a yellow, fatty, bloodless fluid; the liposuction concludes upon drawing the required volume of fat, or when the fat becomes bloody.
After the liposuction, the superficial layer of adipose fat
is undermined with a blunt-tip, 3-mm cannula (which is not connected to a vacuum pump). The breast ptosis is corrected by stimulating the controlled retraction of the incision scar, by undermining the superficial fat of the medial and the lateral upper areas of the breast; the maneuver tightens (retracts) the skin envelope of the breast. Procedurally, the liposuction-only breast reduction procedure concludes with the application of an elastic, foam-tape dressing that molds the reduced breast into its new shape, and lifts it higher upon the chest.
Technical note: For the reduction of very enlarged breasts, the plastic surgeon makes a supplementary incision just above the medial aspect of the inframammary fold. Procedurally, the placement of said incision later allows converting the lipectomy breast-reduction procedure into an inferior-pedicle breast reduction surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts.
Post-operative matters
Convalescence
The patient is discharged from hospital either the same day or the day after the breast reduction operation. Because the liposuction-only procedure featured only a few, small, surgical incisions, the woman quickly recovers her health, usually resuming daily life activities at 3-days post-operative — when the breast-molding dressings are changed; she also resumes her personal hygiene regimen to include washing under a water shower. In the initial convalescence period, the surgical-incision wounds are inspected at 1-week post-operative, during which time the woman has continuously worn a strapless brassière to contain and immobilize her corrected breasts; afterwards, she continuously wears a strapped brassière for 30 days after the breast-reduction operation.
Complications
Early complications include infection
and hematoma
(blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require either surgical
or liposuction
revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although the edema
usually subsides at 2–3 weeks post-operative. To date, no incidence of tissue
necrosis
has been reported; likewise, there have been few reports of lessened nipple-sensation. Generally, the long-term rate of patient-satisfaction is high, provided that the indications for the liposuction-only technique are abided with proper patient selection.
Hypertrophy of breast
Hypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
. In a breast reduction surgery for re-establishing a functional bust
Cleavage (breasts)
Cleavage, anatomically known as the intramammary cleft, is the space between a woman's breasts lying over the sternum. Cleavage is exposed by a garment with a low neckline, such as ball gowns, evening gowns, swimwear, casual tops and other garments....
that is proportionate to the woman’s body, the critical corrective consideration is the tissue viability
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
of the nipple-areola complex
Areola
This article is about the breast tissue. For the entomology term, see the glossary of Lepidopteran terms. For an artistic cloud motif, see aureola. For the cactus feature, see Areole....
(NAC), to ensure the functional sensitivity and lactational
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
capability of the breasts. The indications for breast reduction surgery are three-fold — physical, aesthetic
Aesthetics
Aesthetics is a branch of philosophy dealing with the nature of beauty, art, and taste, and with the creation and appreciation of beauty. It is more scientifically defined as the study of sensory or sensori-emotional values, sometimes called judgments of sentiment and taste...
, and psychological — the restoration of the bust, of the woman’s self-image, and of her mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
. In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to mastopexy (breast lift). Moreover, the correction of gynecomastia
Gynecomastia
Gynecomastia or Gynaecomastia, , is the abnormal development of large mammary glands in males resulting in breast enlargement. The term comes from the Greek γυνή gyné meaning "woman" and μαστός mastós meaning "breast"...
(woman’s breast) is the analogous, enlarged male-breast reduction surgery procedure, wherein there is no consideration of lactation capability.
The patient
PresentationThe woman afflicted with macromastia presents heavy, enlarged breasts (<500 gm per breast per the Shnur Scale) that sag and cause her chronic pains to the head, neck, shoulders, and back; an over-sized bust
Cleavage (breasts)
Cleavage, anatomically known as the intramammary cleft, is the space between a woman's breasts lying over the sternum. Cleavage is exposed by a garment with a low neckline, such as ball gowns, evening gowns, swimwear, casual tops and other garments....
also causes her secondary health problems, such as poor blood circulation
Circulatory system
The circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, etc...
, impaired breathing
Breathing
Breathing is the process that moves air in and out of the lungs. Aerobic organisms require oxygen to release energy via respiration, in the form of the metabolism of energy-rich molecules such as glucose. Breathing is only one process that delivers oxygen to where it is needed in the body and...
(inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassière-strap indentations to the shoulders; and the improper fit of clothes. In the woman afflicted with gigantomastia (<1,000 gm increase per breast), the average breast-volume reduction diminished her over-sized bust by three (3) brassière cup-sizes. The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations that a bodily-disproportionate bust imposes upon a woman; thereby it improves her physical and mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
. Afterwards, the woman’s ability to comfortably perform physical activities previously impeded by over-sized breasts improves her emotional health (self-esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
) by reducing anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
and lessening psychological depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
.
Medical history
The medical history records the woman’s age, the number of children she has borne, her breast-feeding
Breastfeeding
Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers breastfeed for six months or...
practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information, are her history of tobacco smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
and concomitant diseases, breast-surgery and breast-disease histories, family history of breast cancer
Breast cancer
Breast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas...
, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness.
The physical examination records and establishes the accurate measures of the woman’s body mass index
Body mass index
The body mass index , or Quetelet index, is a heuristic proxy for human body fat based on an individual's weight and height. BMI does not actually measure the percentage of body fat. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing...
, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the nipple-areola complex (NAC), and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight, kyphosis
Kyphosis
Kyphosis , also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae...
(excessive, backwards curvature of the thoracic region
Thoracic vertebrae
In human anatomy, twelve thoracic vertebrae compose the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae. They are intermediate in size between those of the cervical and lumbar regions; they increase in size as one proceeds down the spine, the upper...
of the spinal column), skin irritation, and skin rash affecting the breast crease (IMF).
Enlarged breasts
EtiologyA woman develops large breasts usually during thelarche
Thelarche
Thelarche is the onset of secondary breast development, usually occurring at the beginning of puberty in girls. Its etymology is from Greek θηλή [tʰelḗ], “nipple” and ἀρχή [arkʰḗ], “beginning, onset”. Thelarche is usually noticed as a firm, tender lump directly under the centre of the nipple...
(the pubertal breast-development stage), but large breasts can also develop postpartum, after gaining weight, at menopause
Menopause
Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
, and at any age. Whereas macromastia usually develops in consequence to the hypertrophy
Hypertrophy
Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It should be distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number...
(over-development) of adipose fat
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
, rather than to milk-gland hypertrophy. Moreover, many women are genetically
Genetics
Genetics , a discipline of biology, is the science of genes, heredity, and variation in living organisms....
predisposed to developing large breasts, the size and weight of which often are increased either by pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
or by weight gain, or by both conditions; there also exist iatrogenic
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
(physician-caused) conditions such as post–mastectomy
Mastectomy
Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. Mastectomy is usually done to treat breast cancer; in some cases, women and some men believed to be at high risk of breast cancer have the operation prophylactically, that is, to prevent cancer...
and post–lumpectomy
Lumpectomy
Lumpectomy is a common surgical procedure designed to remove a discrete lump, usually a benign tumor or breast cancer, from an affected man or woman's breast...
asymmetry. Nonetheless, it is statistically rare for a young woman to experience virginal mammary hypertrophy that results in massive, over-sized breasts, and recurrent breast hypertrophy
Hypertrophy of breast
Hypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
.
The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the over-development of the milk glands
Lactiferous duct
Lactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
or of the adipose tissue
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
, or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild (>300 gm) to the moderate (ca. 300–800 gm) to the severe (<800 gm). Macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging, breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
that is determined by the degree to which the nipple has descended below the inframammary fold (IMF).
Therapeutic approaches
Medical
Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy; yet a weight-reduction regimen for the over-weight woman can alleviate some of the excessive size and volume of her abnormally enlarged breasts. Physical therapy provides some relief for sufferers of neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chaffing, infection, and bleeding.
Surgical
Reduction mammoplasty, surgery or lipectomy, is the technically reliable method for diminishing the size and volume of the enlarged breast. The traditional, surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; yet it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar — around the nipple-areola complex (NAC), where the dark-to-light skin-color transition hides the surgical scar.
Surgical anatomy of the breast
The procedureA reduction mammoplasty to re-size enlarged breasts and to correct breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
resects (cuts and removes) excess tissues (glandular
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
, adipose, skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
), over-stretched suspensory ligaments
Cooper's ligaments
Cooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
, and transposes the nipple-areola complex (NAC) higher upon the breast hemisphere. At puberty
Puberty
Puberty is the process of physical changes by which a child's body matures into an adult body capable of reproduction, as initiated by hormonal signals from the brain to the gonads; the ovaries in a girl, the testes in a boy...
, the breast grows in consequence to the influences of the hormones
Hormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
and progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
; as a mammary gland
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
the breast is composed of lobules of glandular tissue, each of which is drained by a lactiferous duct
Lactiferous duct
Lactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
that empties to the nipple. Most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules — except during pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
and lactation
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
, when breast milk constitutes most of the breast volume.
Composition
Surgically, the breast is an apocrine gland
Apocrine
Apocrine is a term used to classify exocrine glands in the study of histology. Cells which are classified as apocrine bud their secretions off through the plasma membrane producing membrane-bound vesicles in the lumen. This method is also called decapitation secretion...
overlaying the chest — attached at the nipple and suspended with ligaments from the chest — which is integral to the skin, the body integument
Integumentary system
The integumentary system is the organ system that protects the body from damage, comprising the skin and its appendages...
of the woman. The dimensions and weight of the breasts vary with her age and habitus (body build and physical constitution); hence small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750–1,000 gm. Anatomically, the breast topography
Superficial anatomy
Superficial anatomy is a descriptive science dealing with anatomical features that can be studied by sight, without dissecting an organism...
and the hemispheric locale of the nipple-areola complex (NAC) are particular to each woman; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (NAC to IMF).
The arterial blood
Arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...
supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery
Internal thoracic artery
In human anatomy, the internal thoracic artery , previously known as the internal mammary artery , is an artery that supplies the anterior chest wall and the breasts...
(from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries
Intercostal arteries
The intercostal arteries are a group of arteries that supply the area between the ribs , called the intercostal space.* Highest intercostal artery - first and second intercostal spaces...
. Drainage of venous blood
Venous blood
Venous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...
from the breast is by the superficial vein system under the dermis
Dermis
The dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis...
, and by the deep vein system parallel to the artery system. The primary lymph
Lymphatic system
The lymphoid system is the part of the immune system comprising a network of conduits called lymphatic vessels that carry a clear fluid called lymph unidirectionally toward the heart. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated...
drainage system is the retromammary lymph plexus in the pectoral fascia
Pectoral fascia
The pectoral fascia is a thin lamina, covering the surface of the Pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and below it is continuous with the fascia of the...
. Sensation in the breast is established by the peripheral nervous system innervation
Peripheral nervous system
The peripheral nervous system consists of the nerves and ganglia outside of the brain and spinal cord. The main function of the PNS is to connect the central nervous system to the limbs and organs. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the blood–brain...
of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
s, and thoracic spinal nerve 4
Thoracic spinal nerve 4
The thoracic spinal nerve 4 is a spinal nerve of the thoracic segment..It originates from the spinal column from below the thoracic vertebra 4 ....
(T4 nerve) innervates and supplies sensation to the nipple-areola complex.
Mechanical structures of the breast
In realizing the breast-reduction corrections, the plastic surgeon takes anatomic
Human anatomy
Human anatomy is primarily the scientific study of the morphology of the human body. Anatomy is subdivided into gross anatomy and microscopic anatomy. Gross anatomy is the study of anatomical structures that can be seen by the naked eye...
and histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
account of the biomechanical
Biomechanics
Biomechanics is the application of mechanical principles to biological systems, such as humans, animals, plants, organs, and cells. Perhaps one of the best definitions was provided by Herbert Hatze in 1974: "Biomechanics is the study of the structure and function of biological systems by means of...
, load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (Poisson’s ratio of ∼0.5).
- Rib cage. The 2nd, 3rd, 4th, 5th, and 6th ribs of the thoracic cage are the structural supports for the mammary glands.
- Chest muscles. The breasts overlay the pectoralis major musclePectoralis major muscleThe pectoralis major is a thick, fan-shaped muscle, situated at the chest of the body. It makes up the bulk of the chest muscles in the male and lies under the breast in the female...
, the pectoralis minor musclePectoralis minor muscleThe pectoralis minor is a thin, triangular muscle, situated at the upper part of the chest, beneath the pectoralis major.-Origin and insertion:...
, and the intercostal muscles (between the ribs), and can extend to and cover a portion of the (front) anterior serratus muscle (attached to the ribs, the rib muscles, and the shoulder blade), and to the rectus abdominis muscle (a long, flat muscle extending up the torso, from pubic bone to rib cage). The body posture of the woman exerts physical stresses upon the pectoralis major muscles and the pectoralis minor muscles, which cause the weight of the breasts to induce static and dynamic shear forces (when standing and when walking), compression forces (when lying supine), and tension forces (when kneeling on four limbs). - Pectoralis fascia. The pectoralis major muscle is covered with a thin superficial membrane, the pectoral fasciaPectoral fasciaThe pectoral fascia is a thin lamina, covering the surface of the Pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and below it is continuous with the fascia of the...
, which has many prolongations intercalated among its fasciculi (fascicles); at the midline, it is attached to the front of the sternumSternumThe sternum or breastbone is a long flat bony plate shaped like a capital "T" located anteriorly to the heart in the center of the thorax...
, above it is attached to the clavicleClavicleIn human anatomy, the clavicle or collar bone is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally...
(collar bone), while laterally and below, it is continuous with the fascia. - Suspensory ligaments. The subcutaneous layer of adipose tissueAdipose tissueIn histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
in the breast is traversed with thin suspensory ligaments (Cooper's ligamentsCooper's ligamentsCooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
) that extend obliquely to the skin surface, and from the skin to the deep pectoral fasciaPectoral fasciaThe pectoral fascia is a thin lamina, covering the surface of the Pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and below it is continuous with the fascia of the...
. The structural stability provided by the Cooper’s ligaments derives from its closely packed bundles of collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
fibers oriented in parallel; the principal, ligament-component cell is the fibroblastFibroblastA fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework for animal tissues, and plays a critical role in wound healing...
, interspersed throughout the parallel collagen-fiber bundles of the shoulder, axilla, and thoraxThoraxThe thorax is a division of an animal's body that lies between the head and the abdomen.-In tetrapods:...
ligaments. - Glandular tissue. As a mammary gland, the breast comprises lobules (milk glands at each lobe-tip) and the lactiferous ductLactiferous ductLactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
s (milk passages), which widen to form an ampulla (sac) at the nipple. - Adipose tissue. The fat tissue of the breast is composed of lipidic fluidLipidLipids constitute a broad group of naturally occurring molecules that include fats, waxes, sterols, fat-soluble vitamins , monoglycerides, diglycerides, triglycerides, phospholipids, and others...
(60–85% weight) that is 90–99 per cent triglycerides, free fatty acids, diglycerides, cholesterol phospholipids, and minute quantities of cholesterolCholesterolCholesterol is a complex isoprenoid. Specifically, it is a waxy steroid of fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in the blood plasma of all mammals. It is an essential structural component of mammalian cell membranes...
estersEsterEsters are chemical compounds derived by reacting an oxoacid with a hydroxyl compound such as an alcohol or phenol. Esters are usually derived from an inorganic acid or organic acid in which at least one -OH group is replaced by an -O-alkyl group, and most commonly from carboxylic acids and...
, and monoglycerides; the other components are water (5–30% weight) and protein (2–3% weight). - The skin envelope. The breast skin is in three (3) layers: (i) the epidermis, (ii) the dermisDermisThe dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis...
, and (iii) the hypodermisHypodermisThe hypodermis, also called the hypoderm, subcutaneous tissue, or superficial fascia is the lowermost layer of the integumentary system in vertebrates. Types of cells that are found in the hypodermis are fibroblasts, adipose cells, and macrophages...
. The epidermis is 50–100 µm thick, and is composed of a stratum corneumStratum corneumThe stratum corneum is the outermost layer of the epidermis, consisting of dead cells that lack nuclei and organelles. The purpose of the stratum corneum is to form a barrier to protect underlying tissue from infection, dehydration, chemicals and mechanical stress...
of flat keratinKeratinKeratin refers to a family of fibrous structural proteins. Keratin is the key of structural material making up the outer layer of human skin. It is also the key structural component of hair and nails...
cells, that is 10–20 µm thick; it protects the underlying viable epidermis, which is composed of keratinizing epithelial cellsEpitheliumEpithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...
. The dermis is mostly collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
and elastinElastinElastin is a protein in connective tissue that is elastic and allows many tissues in the body to resume their shape after stretching or contracting. Elastin helps skin to return to its original position when it is poked or pinched. Elastin is also an important load-bearing tissue in the bodies of...
fibers embedded to a viscous water and glycoproteinGlycoproteinGlycoproteins are proteins that contain oligosaccharide chains covalently attached to polypeptide side-chains. The carbohydrate is attached to the protein in a cotranslational or posttranslational modification. This process is known as glycosylation. In proteins that have segments extending...
medium. The fibers of the upper dermis (“papillary dermis”) are thinner than the fibers of the deep dermis, thus the skin envelope is 1–3 mm thick. The thickness of the hypodermis (adipocyte cells) varies from woman to woman, and body part. The skin of the nipple and areola is further composed of a modified and specialized myoepthelium that is responsible for contraction in response to stimuli.
Surgical procedures
Reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a woman afflicted either with macromastia (<500 gm increase per breast) or with gigantomastia (<1,000 gm increase per breast). Breast reduction surgery has two (2) technical aspects: (i) the skin-incision pattern and the skin- and glandular-tissue excision technique applied for access to and removal of breast parenchyma
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
tissue. The incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars; (ii) the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of nerves and blood vessels (arterial
Arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...
and venous
Venous blood
Venous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...
) that ensure its tissue viability
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
.
The specific reduction mammoplasty procedure is determined by the volume of breast tissues (glandular
Lactiferous duct
Lactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
, adipose
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
, skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
) to be resected (cut and removed) from each breast, and the degree of breast ptosis present: Pseudoptosis (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold); Grade I: Mild ptosis (the nipple is below the IMF, but above the lower pole of the breast); Grade II: Moderate ptosis (the nipple is below the IMF; yet some lower-pole breast tissue hangs lower than the nipple); Grade III: Severe ptosis (the nipple is far below the IMF; no breast tissue is below the nipple). The full, corrective outcome of the surgical re-establishment of a bodily-proportionate bust becomes evident at 6-months to 1-year post-opertaive, during which period the reduced and lifted breast tissues settle upon and into the chest. The post-operative convalescence is weeks long, depending upon the corrections performed; and some women might experience painful breast-enlargement during the first post-operative menstruation
Menstruation
Menstruation is the shedding of the uterine lining . It occurs on a regular basis in sexually reproductive-age females of certain mammal species. This article focuses on human menstruation.-Overview:...
.
Contraindications
Breast reduction surgery cannot be performed if the woman is lactating
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
, or has recently ceased lactating; if her breasts contain unevaluated tissue masses
Breast cancer
Breast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas...
, or unidentified microcalcifications; if she is suffering a systemic illness; if she is unable to understand the technical limitations of the plastic surgery; and her inability to accept the possible medical complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
of the procedure.
I. Inferior pedicle technique (Anchor pattern, inverted-T incision, Wise pattern)
The inferior pedicle (central mound) features a blood vessel supply (arterial and venous) for the nipple-areola complex (NAC) from an inferior, centrally-based attachment to the chest wall. The skin pedicle maintains the innervation and vascular
Circulatory system
The circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, etc...
viability of the NAC, which produces a reduced, sensitive breast with full lactational
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
capability and function. The volume and size reduction of hypertrophied breasts
Hypertrophy of breast
Hypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
is performed with a periareolar incision to the nipple-areola complex, which then extends downwards, following the natural curve of the breast hemisphere. After cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the nipple-areola complex is transposed higher upon the breast hemisphere; thereby the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the woman’s person. Nonetheless, breast-reduction with an inferior pedicle, occasionally produces breasts that appear squared; yet, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia.
II. Vertical scar technique (lollipop incision)
The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision scars
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
and a nipple-areola complex (NAC) elevated by means of a pedicle (superior, medial, lateral) that maintains the biologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
and functional
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
viability of the NAC. The increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the NAC . The vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars.
III. Horizontal scar technique
The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a nipple-areola complex (NAC) pedicle. To elevate the NAC, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the Anchor pattern). The horizontal-scar technique best applies to the woman whose over-sized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed NAC. The potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold.
IV. Free nipple-graft technique
The breast reduction performed with the free nipple-graft technique transposes the nipple-areola complex (NAC) as a tissue
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
graft without a blood supply, without a skin and glandular pedicle. The therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. The therapeutic disadvantage is a breast without a sensitive nipple-areola complex, and without lactational
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
capability. The medically indicated candidates are: the woman whose health presents a high risk of ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
(localized) tissue
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
) of the nipple-areola complex
Areola
This article is about the breast tissue. For the entomology term, see the glossary of Lepidopteran terms. For an artistic cloud motif, see aureola. For the cactus feature, see Areole....
, which might cause tissue necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
; the diabetic woman; the woman who is a tobacco smoker
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
; the woman whose over-sized breasts have an approximate NAC-to-IMF measure of 20 cm; and the woman who has macromastia requires much resecting of the breast tissues.
V. Liposuction-only technique (lipectomy)
The breast reduction performed with the liposuction-only
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...
technique usually applies to the woman whose over-sized breasts require the removal of a medium volume of internal tissue; and to the woman whose health precludes her being under the extended anaesthesia usual to surgical breast-reduction operations. The ideal lipectomy candidate is the woman whose low-density breasts are principally composed of adipose tissue
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
, have a relatively elastic skin envelope, and manifest mild ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
. The therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior, hence, a shorter post-operative healing period for the incision scars; the therapeutic disadvantage is limited breast-reduction volumes.
Lejour technique breast reduction
The treatment of macromastia and gigantomastiaHypertrophy of breast
Hypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
with the Lejour technique applies a vertical-incision, a superior pedicle, breast liposuction
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...
, and wide undermining of the skin of the lower portion of the breast. The technical efficacy of the Lejour breast reduction was established with the study Vertical Mammaplasty and Liposuction of the Breast (1994), which reported 153 reduction mammoplasties performed in 79 patients, wherein an average fat volume of 300 ml was removed from each breast, and the average resection of 480 gm of parenchymal tissue was removed from each breast.
Pre-operative matters
The medical treatment records
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the over-sized breasts, the sternal-notch–to-nipple distances, and the nipple-to–inframammary-fold distances. The woman is instructed about the purposes of the breast reduction surgery, the achievable corrections, the expected final size, shape, and contour of the reduced breasts, the expected final appearance of the breast reduction scars
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
; possible changes in the sensation of the nipple-areola complex
Areola
This article is about the breast tissue. For the entomology term, see the glossary of Lepidopteran terms. For an artistic cloud motif, see aureola. For the cactus feature, see Areole....
(NAC), possible changes in her breast-feeding
Breastfeeding
Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers breastfeed for six months or...
capability, and possible medical complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
. The woman also is instructed about post-operative matters such as convalescence and the proper care of the surgical wounds to the breasts.
Incision-plan delineation — To the breasts of the standing patient, the plastic surgeon delineates the mosque dome skin-incision-plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (IMF), and the vertical axis of the breast, beneath the IMF. The upper-edge of the (future) nipple-areola complex (NAC) is marked slightly below the IMF-level, and a semicircle of 16-cm maximum diameter. In relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. The circumference of the (future) nipple-areola complex is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future NAC circumference; the incision-plan delineation continues down as a cone, and around the marked circumference.
Operative technique
The patient is laid supine upon the operating table so that the surgeon can later raise her to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. Afterwards, the pedicle epidermis surrounding the NAC (nipple-areola complex) is cut, and adipose tissue is liposuctioned from the breast. The medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. Then, the nipple-areola complex is transposed higher upon the breast hemisphere. The pillars of parenchymal tissue
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
are approximated (joined), and the skin envelope is sutured.
Notes
- Biological: The resected tissue is submitted to histopathologicPathologyPathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
examination, because sub-clinical breast cancerBreast cancerBreast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas...
foci occur in 0.1–0.9 per cent of the tissueHistologyHistology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
specimens.
- Technical: The original Lejour technique incision plan had no horizontal limbs, and so did not produce horizontal scars; however, contemporary variants, such as the Modified Lejour Technique, employ small, horizontal incisions along the inframammary fold, in order to avoid redundant skin folds, especially in the reduction of very over-sized breasts.
Post-operative matters
The woman is instructed to resume her normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassière; the convalescence regimen is for 3-months post-operative. She is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within 1–6 months post-operative; yet some cases might require surgical revision of the vertical scar. Scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications.
Complications
The post-operative complications occurred included seroma
Seroma
A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....
, wound dehiscence
Dehiscence
Dehiscence can refer to:*Dehiscence is the spontaneous opening at maturity of a plant structure, such as a fruit, anther, or sporangium, to release its contents.*Wound dehiscence is a previously closed wound reopening....
, hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
; whereas partial NAC necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
occurred in 10 per cent of the reduced breasts; yet, after refinement of the Lejour technique, the study Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases (1999), reported a reduced incidence rate of 7.0 per cent in the 324 breast reductions performed in 167 patients. Moreover, the incidence of such post-operative complications is greater among the women whose breasts required large-volume resection of the parenchyma
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
; in women who were obese
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
; in women who were tobacco smokers
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
; and in young women. Furthermore, wound dehiscence, epidermolysis, adipose tissue
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
necrosis, and infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
occur less among women who undergo Lejour-technique breast reduction, than among women who undergo a periareolar, Anchor pattern breast-reduction, or an inferior-pedicle breast reduction. Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 per cent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 per cent of the women; and total NAC insensitivity occurs in 1.0 per cent of women.
Liposuction-only technique
IndicationsThe reduction of over-sized breasts by liposuction only (lipectomy) is indicated when a minor-to-moderate volume-reduction is required, and there is no breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
to correct. Further indications for lipectomy are presented by: (i) the woman who requires a large-volume reduction, and wants un-scarred, sensate breasts, yet will accept a degree of ptosis; (ii) the woman who requires a secondary mammoplasty to correct an asymmetric breast, by up to one (1) brassière cup-size; and (iii) the girl afflicted with virginal breast hypertrophy
Hypertrophy of breast
Hypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
, as a temporary procedure performed before the conclusion of her thelarche
Thelarche
Thelarche is the onset of secondary breast development, usually occurring at the beginning of puberty in girls. Its etymology is from Greek θηλή [tʰelḗ], “nipple” and ἀρχή [arkʰḗ], “beginning, onset”. Thelarche is usually noticed as a firm, tender lump directly under the centre of the nipple...
(the pubertal breast-growth phase), given the hypertrophy’s high rate of recurrence.
Contraindications
Breast reduction by liposuction only cannot be performed upon a woman whose mammogram indicates that the over-sized breast is principally composed of hypertrophied milk glands
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
. Furthermore, liposuction mammoplasty also is contraindicated for any woman whose mammograms indicate the presence of unevaluated neoplasms; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope.
Consultation — The plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The woman is informed of the alternative, surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
reduction techniques available for diminishing her over-sized breasts; of the consequent surgical scars
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
; of the possible loss of breast sensation; of the possible impairment of lactation
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
capability; and of the posible impairment of breast-feeding
Breastfeeding
Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers breastfeed for six months or...
functions. The woman is further informed of the possible medical complications, and is shown surgical photographic records of the average outcomes of breast-reduction surgery. The surgeon answers the woman’s questions to assist her in establishing realistic expectations (self-image) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the volume of her breasts, a secondary, surgical breast-reduction procedure can be performed later.
The measures of the bust — A liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the woman’s breasts, chest, and torso. Yet the measures of the bust are established in order to determine the required degree(s) of correction; thus, with the patient sitting erect, for each breast, the surgeon records the jugular-notch-to-nipple distances, the nipple-to-inframammary-fold distances, and any asymmetries. Afterwards, the anaesthetized patient is laid supine upon the operating table, with her arms laterally extended (abducted) in order to fully expose the breasts.
Anaesthestic preparation — To limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast’s circulatory system is established with an anaesthetic solution (lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...
+ epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
in saline solution) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforation cannula
Cannula
A cannula or canula is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of data...
, the anaesthetic infiltration begins at the deep plane of the breast, and continues as the cannula is withdrawn towards the superficial plane of the breast. The entire area of the breast is infiltrated with the anaesthetic solution until the tissues become tumescent (firm). Moreover, as required by the patient’s physique, an intravenous (IV) pressure bag can be applied to hasten the infiltration; after the anaesthetic has numbed the breast, the plastic surgeon begins the lipectomy breast-reduction.
Operative technique
The surgeon effects a stab incision just above the lateral aspect of the inframammary fold (IMF), piercing the skin 2-cm above the inframammary fold, in the midline. The pre-tunnelling is performed with the blunt-tip, multi-perforation cannula used to infiltrate the anaesthetic solution to the breast tissues. A blunt-tip, 4-mm cannula, connected either to a medical-grade vacuum pump or to a syringe, is used to aspirate (suck) the adipose fat
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
. The cannula is maneuvered laterally (in fanning movements), beginning in the deep plane of the breast and concluding in the superficial plane of the breast; the adipose fat
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
sucked from the breast is a yellow, fatty, bloodless fluid; the liposuction concludes upon drawing the required volume of fat, or when the fat becomes bloody.
After the liposuction, the superficial layer of adipose fat
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
is undermined with a blunt-tip, 3-mm cannula (which is not connected to a vacuum pump). The breast ptosis is corrected by stimulating the controlled retraction of the incision scar, by undermining the superficial fat of the medial and the lateral upper areas of the breast; the maneuver tightens (retracts) the skin envelope of the breast. Procedurally, the liposuction-only breast reduction procedure concludes with the application of an elastic, foam-tape dressing that molds the reduced breast into its new shape, and lifts it higher upon the chest.
Technical note: For the reduction of very enlarged breasts, the plastic surgeon makes a supplementary incision just above the medial aspect of the inframammary fold. Procedurally, the placement of said incision later allows converting the lipectomy breast-reduction procedure into an inferior-pedicle breast reduction surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts.
Post-operative matters
Convalescence
The patient is discharged from hospital either the same day or the day after the breast reduction operation. Because the liposuction-only procedure featured only a few, small, surgical incisions, the woman quickly recovers her health, usually resuming daily life activities at 3-days post-operative — when the breast-molding dressings are changed; she also resumes her personal hygiene regimen to include washing under a water shower. In the initial convalescence period, the surgical-incision wounds are inspected at 1-week post-operative, during which time the woman has continuously worn a strapless brassière to contain and immobilize her corrected breasts; afterwards, she continuously wears a strapped brassière for 30 days after the breast-reduction operation.
Complications
Early complications include infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
and hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
(blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require either surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
or liposuction
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...
revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although the edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
usually subsides at 2–3 weeks post-operative. To date, no incidence of tissue
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
has been reported; likewise, there have been few reports of lessened nipple-sensation. Generally, the long-term rate of patient-satisfaction is high, provided that the indications for the liposuction-only technique are abided with proper patient selection.
See also
- Breast augmentationBreast augmentationBreast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
- Breast implant
- Breast ironingBreast ironingBreast ironing is the pounding and massaging of a pubescent girl's breasts using heated objects in an attempt to make them stop developing or disappear...
- MastopexyBreast liftMastopexy is the mammoplasty procedure for correcting the size, contour, and elevation of sagging breasts upon the chest...
- Breast reconstructionBreast reconstructionBreast reconstruction is the rebuilding of a breast, usually in women. It involves using autologous tissue or prosthetic material to construct a natural-looking breast. Often this includes the reformation of a natural-looking areola and nipple...
- Hypertrophy of the breastHypertrophy of breastHypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
(gigantomastia and macromastia) - Virginal breast hypertrophy
- Multiple breast syndromeMultiple breast syndromeMultiple Breast Syndrome is a condition and a form of atavism where a person is born with, or develops, extra breasts. It is most prevalent in male humans, and often goes untreated as it is mostly harmless...