What are the Surgical Techniques?
Through the years there have been many variations on the techniques to attempt to aesthetically decrease the size of the breasts and these have evolved into two principal patterns. The original “keyhole” pattern devised in the late 1960’s remains the standard external skin pattern. However, treatment of the nipple and remaining gland has changed in recent years. It is now possible to incise the skin flaps and remove most of the gland and subcutaneous tissue from the medial/lateral upper quadrants but leave the entire central core of the breast gland, nipple and areolar complex intact. In this way, it is often possible to preserve the enervation from the fourth intercostal nerve to have sensate and erectile nipples.
The circumareolar procedure involves the removal of a toroidal (lifesaver) section of skin and some subcutaneous fat with the elevation of the nipple areolar complex and removal of a minimum amount of skin and tissue. Liposuction enables us to sculpt the remaining breast gland and remove a few hundred ccs. Without additional scars. A coronal stitch is passed around subcutaneously through the skin of the greater outer circle and cinched like a purse string to approximate the smaller inner areolar circle.
In some cases it is possible to reduce the size of the breast substantially by liposuction alone, there are no scar at all on the breast, just a 2 or 3 millimeter mark in the arm- pit.
The keyhole pattern has the advantage of producing a well defined breast contour with dependable nipple projection and general cone shape. For the patient with medium sized breasts, it may be possible to maintain intact nerves and function.
The circumareolar procedure has the advantage of a single circumareolar scar that has the appearance of a halo and is not perceived as a scar because of its location between the pigmented areola and the breast skin.
The keyhole procedure has the disadvantage of an obvious scar shaped like a broad letter “T”.Often the points of this scar being under great tension suffer from delayed healing because of the decreased blood supply to these remote corners of the flap that is fed mostly by the dermal plexis.If the breasts are too long, it may be necessary to transplant the nipples as free grafts.
The use of the circumareolar approach is limited to those breasts that are somewhat tapered in shape and those that need the minimum amount of reduction, that is, where the nipple may braised only two or three centimeters and the volume reduction is limited to a few hundred ccs.Although the scar is only circumareolar, in time this scar may spread due to tension, and may become more noticeable in subsequent years.
Breast reduction is indicated for those patients who feel their breasts are too large for comfort.Most insurance companies will cover breast reduction if they are large breasts that cause postural changes, grooving of the shoulders from bra strap pressure, chest pain, back pain, arm and shoulder pain, and peripheral nerve compression, or if the breasts are so large as to encumber the patient’s work or carrying capacity, i.e. several liters in size. In males, breast reduction is also performed for gynecomastia and this can usually be accomplished with liposuction with no incisions on the breast itself.
Modern techniques provide for tourniquet control and local anesthesia with sedation so that breast reduction can be performed safely on an outpatient basis, often without transfusion.
Infection or swelling can have devastating effects on usually dependable results of breast reduction. Fortunately, these are very rare, occurring in less than 1% of the cases and can usually be treated on an outpatient basis by antibiotics and drainage. More frequently some loss of skin, ranging from a few millimeters at the wound edge to a few centimeters, may occur from pressure necrosis as a result of tension on the wound of the inferior pole of the breasts. Some degree of this tension and necrosis may be seen in 5% to 10% of the cases and it is usually treated by watchful waiting and scar revision after six months of healing. This is more common in the largest reductions where more tension is necessary and often, even if no necrosis occurs, scar revision is indicated after a year or so, once some stretching of the inferior pole may decrease breast projection.
Although loss of sensation and lactation are always possible, it is not that common; and by far, the majority of breast reductions have good nipple-areolar sensation.
With the classic keyhole pattern, the scars are very prominent and obvious. These are bright pink or red lines that expend around the nipple, along the crease under the breast, and the mid portion of the bottom of the breast. Over the years, these scars fade to become a less noticeable white line, although they are always present. Because there is so much weight resting on the lower portions of these wounds, often the scars stretch considerably over a period of years. Therefore,scar revision is indicated in about 20% of these cases. After a year of stretching and equilibrium,scar revision can restore a youthful shape and, since most of the stretching is by then complete, the need for further revision is not likely.
In our practice, breast reduction patients are among our happiest, even when their results are cosmetically less than perfect due to scarring. When a woman has been encumbered with very large breasts she is physically burdened by these massive weights and feels conspicuous in any clothes. Functionally and psychologically, reduction of such breasts to a normal size has a very positive effect on the patient.