If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Address: Department of Plastic and Reconstructive Surgery, Innsbruck University Hospital, Anichstrasse 35, Innsbruck A-6020, Austria. Tel.: +43-512-504-2730; fax: +43-512-504-2735
Department of Plastic and Reconstructive Surgery, Innsbruck University Hospital, Anichstrasse 35, Innsbruck A-6020, AustriaLudwig Boltzmann Institute for Quality Control in Plastic and Reconstructive Surgery, Innsbruck, Austria
In patients who undergo breast reconstruction after unilateral mastectomy for breast cancer, the contralateral natural breast is often disproportionately large in comparison with the reconstructed breast. Such patients may express a desire to have reduction of the larger breast in order to achieve symmetry. A novel technique is described for breast reduction in such cases, which, despite the presence of visible scars, found acceptance among patients. The primary goal of reduction mammaplasty in these cases is symmetry, keeping in mind the shape, volume and degree of ptosis of the reconstructed breast, and not achieving youthful-looking breasts.
Bilateral reduction mammaplasty of hypertrophic or hyperplastic breasts is performed primarily for either health or aesthetic reasons. In the former case, the goal of surgery is to reduce adverse health effects, such as back, neck and shoulder pain, shoulder grooves caused by brassiere straps, intertrigo and the inability to perform physical activities. Surgery also helps to restore self-image and self-confidence, which may be affected by disproportionately large breasts.
Improvements in physical well-being are accompanied by the psychological effects of improved appearance.
The goal of surgery performed primarily for aesthetic reasons is to reconstruct the breasts in such a way that they acquire a firm youthful appearance, with upper-breast fullness, mound elevation and little ptosis, and so that they are in proportion to the rest of the body.
Unilateral reduction mammaplasty is performed on a breast that is disproportionately larger than the contralateral normal-sized breast. Restoration of symmetry and proportion in women with asymmetrical breasts is a not-infrequent aesthetic request.
There are several standard techniques used in reduction mammaplasty.
The choice depends on the age of the patient, the degree of ptosis, the nature of the skin over the breasts (whether it is elastic or inelastic), the volume that needs to be resected, the proportion of fat to glandular tissue, the nature of the glandular tissue and the expectations and wishes of the patient.
Some important considerations in any reduction mammaplasty are to maintain sensibility of the nipple–areola complex
and, for aesthetic reasons, to make as few incisions as possible in order to reduce the number and length of the scars, and to place them where they remain invisible.
Reduction mammaplasty, however, is being increasingly performed on breasts that are out of proportion to the reconstructed contralateral breasts after mastectomy for breast cancer. The use of autologous tissue derived from the abdomen or buttocks
has become more frequent in reconstructive procedures. Adequate tissue can be harvested to reconstruct a breast with the volume of the resected breast, but, in cases where the resected breast is hypertrophic to begin with, it is reconstructed so as to be proportionate to the rest of the body.
In mature women, breasts reconstructed with autogenous flaps may have a normal feel, a natural appearance, a good volume and a certain amount of ptosis. These characteristics cannot be achieved by any other reconstructive procedure. In certain cases, asymmetry is noted, with the unaffected breast being larger than the reconstructed one. In these cases, the aim of reduction mammaplasty is not to restore a youthful appearance to the breast by eliminating ptosis (for which there are several standard techniques) but rather to create symmetry, keeping in mind the shape, volume and degree of ptosis of the reconstructed breast.
With this goal in mind, I describe a novel method of breast reduction.
1. Surgical technique
Mastectomy is usually performed via a horizontal elliptical incision, resulting in a transverse scar on the anterior chest wall. During secondary reconstruction, this transverse scar is excised, the skin is undermined both caudally and cranially, and resected if it is too thin or has been irradiated, and the flap is introduced through this transverse oval defect.
Before mammaplasty is performed to restore symmetry in patients who have previously undergone mastectomy, mammography is performed to ensure that the remaining breast is free from cancer.
To determine the volume of reduction of the contralateral breast, markings are drawn with a marking pen on the reconstructed breast, with the patient standing, in the following manner: the sternal notch is marked, and a midline vertical line is drawn from the sternal notch as a reference; a line is drawn from the midclavicular point to the inframammary fold, and another line is drawn from the sternal border of the ipsilateral side to the anterior axillary line at the level of the greatest convexity of the reconstructed breast; the position of the nipple is marked at the intersection of these two lines. These markings are then transposed to the contralateral breast. The diameter (length and breadth) of the nipple–areola complex is marked on the breast to be reduced, and is usually 5–6 cm.
If the parenchyma to be resected lies cranially to the areola, a semicircular skin incision corresponding to half the circumference of the areola is marked on the transverse incision.
Surgery is performed with the patient supine, with the arms close to the torso. The patient is elevated to an upright position only for checking whether the breasts are symmetrical.
Depending on the findings of the mammography, glandular tissue is resected either cranially or caudally from the nipple–areola complex and sometimes, if necessary, from the central area of the parenchyma. Tissue resection is done transversely.
The skin around the areola is de-epithelialised either both cranially and caudally or on only one side. Excess skin between the two incisions is resected. The reduced areola itself remains attached to the dermis and is thus well vascularised and innervated. Depending on the distance between the lower border of the areola and the submammary crease, which should not exceed 8 cm even in relatively large breasts, no resection is performed caudally because of the risk of damaging the vascular supply and innervation.
In addition, the skin is undermined cranially up to the third or fourth ribs. The remaining glandular tissue is sutured to the pectoralis major muscles with interrupted 2/0 sutures of a nonabsorbable material. Wound closure is performed in two layers. Suction-drainage tubes are inserted into the wound and removed after 24 h or more, depending on the amount of secretion from the wound. An elastic bandage is applied.
At the same time, reconstruction of the nipple on the contralateral breast is often performed, together with minor corrections to the reconstructed breast or scar revision.
2. Patients
Between 2000 and 2002, 10 patients were treated according to the procedure described above, eight of whom had had unilateral autologous breast reconstruction after modified radical mastectomy for breast cancer and wished to restore symmetry by reduction mammaplasty of the remaining breast (Fig. 1, Fig. 2) . The remaining two patients expressed a desire to have their hypertrophied breast reduced at the same time as undergoing modified radical mastectomy of the cancer-bearing breast. In these two patients, both mastectomy and the transverse reduction mammaplasty were performed in a single operation.
Fig. 1(A) A 37-year-old patient whose left breast has been reconstructed with autologous tissue after mastectomy, showing the preoperative markings on the ptotic right breast, which is to be reduced. (B) Appearance two years postoperatively.
Fig. 2(A) A 56-year-old patient after mastectomy. (B) The left breast has been reconstructed with autologous tissue and the right breast has been reduced using transverse resection. (C) Preoperative and (D) postoperative views of the right breast.
The age of the patients ranged from 37 to 62 years. The weight of the resected tissue was 180–940 g (mean: 540 g). There were no complications of any kind. There were no wound-healing problems and no cases of fat necrosis. In two patients, hypertrophy of the lateral part of the scar occurred in the first postoperative year, and the scar was thus visible. In no cases were there any changes in the sensibility of the nipple–areola complex. All patients expressed satisfaction with the results achieved at the end of the first year.
3. Discussion
More and more patients are opting for autologous-tissue transfer for breast reconstruction after modified radical mastectomy. Breasts so reconstructed have a natural feel and appearance. If the cancer-bearing breast is hypertrophic, the surgeon attempts to reconstruct the breast so that it has a shape and size that are in harmony with the rest of the body. A certain degree of ptosis is also present. The remaining normal breast might, in some patients, have a far greater degree of ptosis and also be larger than the reconstructed breast. At the half-yearly check-up, patients with unequal breasts often express a desire for reduction mammaplasty in order to achieve symmetry. Restoring symmetry in these patients requires a procedure that, while resecting excess volume, permits a degree of ptosis similar to that present in the flap-reconstructed breast. The goal here is to achieve symmetry rather than a youthful-looking breast.
The method outlined above is ideally suited to this purpose. It permits almost total resection of the glandular tissue in a prophylactic fashion, in accordance with the findings of preoperative mammography. The nipple–areola complex is maintained on an inferior pedicle and, consequently, can be shifted cranially to its new position without endangering its vascularisation. Sensibility is maintained. It is relatively easy to achieve symmetry with the reconstructed breast. The reduced breast has a natural form and contour. The main disadvantage of this method is the visible horizontal scar. Patients must be made aware of this scar in preoperative discussions, and should be shown pictures so that they have a clear idea of what to expect after surgery. The patients in this series, however, did not go topless before the operation and, consequently, were not unduly disturbed by the knowledge that surgery would leave a visible horizontal scar. It is possible that they had become accustomed to bearing such a scar on the post-mastectomy reconstructed breast.
In summary, transverse resection is a simple and efficient technique of reduction mammaplasty, which can be used to reduce a disproportionately large ptotic breast and achieve symmetry with a flap-reconstructed breast after modified radical mastectomy for breast cancer.
References
Stroembeck J.O
Report of a new technique based on the two-pedicled procedure.
00127-9&id=gr1.jpg){kind=link}
00127-9&id=gr2.jpg){kind=link}