Evolution of the Vertical Reduction Mammaplasty: The S Approach

The vertical reduction mammaplasty has been popularized over recent years. It always produces marked puckering of the excess skin and requires revision surgery for the persistent dog-ears that develop. Minor complications are often common. As a result, the evolution with S approach is developed. A series of 36 consecutive patients who underwent the S approach reduction mammaplasty is presented. The S approach can be described as having 1) superior dermoglandular pedicle, 2) simple and safe S-shaped skin marking, 3) suspension of the residual glandular tissues transversely to the periosteum of the 5th rib, and 4) short-scar closure. The surgical techniques are described in a step-by-step fashion. An analysis is made of the results obtained from these patients. The mean follow-up period of this study is 21 months. As a result of surgical operation, the symptoms of breast hypertrophy were markedly improved. According to patient assessment, neck, back, or chest pain decreased from 64% to 25%, shoulder grooving improved from 56% to 25%, stooped posture decreased from 42% to 14%, intetrigo improved from 36% to 8%, psychological embarassment decreased from 33% to 8%. The postoperative complications included minimal areolar epidermolysis (11%), hypertrophic scar (8%), etc. All mammograms revealed hypertrophic patterns of the breast. The glandular tissues removed had a mean of 480 g from each breast. Two breasts (3%) had fibroadenomas. The sternal notch–nipple distance changed from a mean of 30.5 cm preoperatively to 20.5 cm, the length of infraareolar scar was 9 cm in average. Eighty-one percent of patients had minimal postoperative ptosis, and the sensitivity of nipple–areola complex was unchanged in 75% of patients. Nine patients (24%) retained the ability to lactate for more than 1 month postoperatively. Twenty-two patients (61%) were very satisfied with their operation, and eight (22%) were adequately satisfied. The technique presented is a simple and safe procedure that provides satisfactory results for patients with breast hypertrophy.     

Specimen Radiography: An Assessment Method for Reduction Mammaplasty Materials

Although, one out of every eight women has a risk of developing breast cancer, the reported incidence of breast carcinoma detection in reduction mammaplasty materials is rather low. To our knowledge, specimen radiography, which is used for breast biopsies has not been used for the assessment of breast reduction materials. We investigated the applicability of specimen radiography and its potential benefits in detection of the breast pathologies, especially malignancies in reduction mammaplasty materials. Forty patients scheduled for reduction mammaplasty operation were included. In all cases an inferior pedicle reduction technique was preferred and the radiographs of the resected breast tissues were taken immediately. The radiographs were evaluated for any possible pathologic appearance and all abnormal findings were marked. For the histopathologic evaluation, in addition to the random sampling of the pathologist, any marked areas were also microscopically examined. In two cases fibrocystic changes were found in radiographs and the same results were obtained in the histological examination. No false negative mammogram was seen. Specimen radiography, which is applicable for breast reduction materials is an easy and cheap method and does not cause any patient discomfort. It seems that the radiographs of reduction mammaplasty materials are useful to provide guidance to the pathologist during tissue sampling for microscopic examination especially when large amounts of breast tissue is excised.     

Liposuction Breast Reduction

All breast reductions since 1996 have been performed with only liposuction. Removal of up to 2250 ml per breast has been obtained in 45 patients, without any complications. Significant skin retraction results from a very superficial subcutaneous liposuction, with a significant volume reduction of the gland. One bilateral mastopexy was performed subsequently.     

Vertical Mammaplasty for Breast Reduction

All of our breast reduction surgeries during the last 3 years have been done in such a manner that only the vertical scar is left. Due to placing a precise marking to obtain a very nice projected breast reduced to an appropriate size and with no complications, significant patient satisfaction has been achieved. The reduction of the scar is down to almost 40% of what it would have been with an inverted ``T' scar.     

Mammaplasty for Mild and/or Ptotic Breast Through Short Incision at the Inframammary Sulcus: A Personal Approach

Small to moderate pexy and breast reduction have been treated through a 5-cm length access view incision placed at the inframammary sulcus. Resection of up to 450 g in each breast are obtained. Overlapping and plication of two glandular flaps dissected from the lower breast quadrants complete the suspension and fixation of the breast in its ideal position. The areola remain untouched.     

Wineglass Pattern for Vertical Mammaplasty

The ideal reduction mammaplasty technique should create a pleasing breast shape with minimal scarring. The long and conspicuous scar associated with the classic inverted ``T' pattern mammaplasty techniques are not acceptable for many patients. Periareolar mammaplasty techniques cause less scarring, but they have major disadvantages such as scar widening, areolar distortion, and insufficient breast projection. We used a new pattern for vertical mammaplasty to overcome the insufficient breast projection caused by the round block technique and applied it to 51 patients during the last 3 years. This method results in a single vertical scar and a periareolar scar, allows sufficient volume reduction, and provides good breast shape and projection; the results are durable. This procedure is safe, causes few complications, and is easy to learn and perform.     

Augmentation Mammaplasty with a New Cohesive Gel Prosthesis

We present our experience with augmentation mammaplasty on 14 patients with a thin chest wall and poor subcutaneous tissue. Thanks to Polytech Silimed code 20675, a new anatomical prosthesis filled with ``soft' cohesive gel, the lodging in a subglandular position was possible without anomalous salience in the upper pole, and a more natural mammary profile was achieved without capsular contracture, dislocation, or misplacement of the mammary implants.     

Histologic Profiles of Breast Reduction Specimens

Reduction mammaplasty is one of the most common procedures performed by plastic surgeons all around the world. This procedure is performed for aesthetic or reconstructive purposes, but also offers the opportunity to examine all resected breast tissue histopathologically. The purpose of this study was to evaluate the histologic diagnoses of the reduction mammaplasty specimens retrospectively and to determine the incidence of breast lesions in otherwise asymptomatic and healthy women. Therefore, 149 patients who had undergone reduction mammaplasty were reviewed with regard to their histologic diagnoses. We found that 61% of these women have pathologic alterations in at least one of their breasts, so each patient who requests a breast reduction surgery should be evaluated carefully and the specimens should be handled with particular care.     

Mammaplasty Utilizing the Periareolar Approach

An analysis of 300 cases of reduction mammaplasty done utilizing a periareolar approach at the University Hospital of the State of Rio de Janeiro and our own private clinic during the period from September 1989 through October 1995 is presented in this article. The technical evolution of this procedure is described in detail as well as how the complications were eliminated and the aesthetic results improved. A thorough analysis of recommendations and comments on the results are made by the authors.     

Mammaplasty with a Periareolar Dermal Cloak for Glandular Support

Analyzing the main surgical element of mammaplasty, almost all procedures incorporate a smaller or bigger dermal flap. The periareolar dermal cloak is a dermis flap corresponding to the skin pattern and pedicled to the nipple areola. The shape of the flap can be tailored as required but 2 cm of the dermis flap around the nipple should not be touched. The periareolar dermal flap has been used as a cloak; this dermal cloak is suitable for positioning the nipple and covering a part of the glandular tissues with support. With fastening of the cloak, a better tone of the breast tissues can be achieved. Mastopexy, reduction mammaplasty presented by technical detail of dermal cloak positioning and glandular support, has been done in 178 breast operations since 1992. The dermal cloak technique was used in 114 cases. The technique, clinical results, advantages, disadvantages, and complications are discussed.     

A Triangular Suture to Simplify Reduction Mammaplasty

A technique to facilitate correct preoperative marking for an en bloc resection in superiorly based mammaplasty is presented. A temporary triangular suture is placed to control the estimated resection lines for the removal of the medial and lateral tissue block. The described technique helps to avoid the formation of medial and lateral dog ears and the unpleasant and visible scars that result.     

Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy Is Accurate in Breast Cancer Patients with a Clinically Negative Axillary Nodal Status at Presentation

Background In breast cancer, neoadjuvant chemotherapy (NAC) is widely used in order to enable a conservative surgery. In patients treated with NAC, the use of sentinel lymph node (SLN) biopsy, which is a good predictor of the axillary nodal status in previously untreated patients, is still discussed. The aim of our study was to determine clinicopathological factors that may influence the accuracy of SLN biopsy after NAC. Methods Between March 2001 and December 2006, 129 patients with infiltrating breast carcinoma were studied prospectively. Preoperatively, all of them underwent NAC. At surgery, SLN biopsy followed by axillary lymph node (ALN) dissection was performed. Lymphatic mapping was done using the isotope method. Results The SLN identification rate was 93.8% (121/129). Fifty-six out of the 121 successfully mapped patients had positive ALN. Eight out of these 56 patients had tumor-free SLN (false-negative rate of 14.3%). The false-negative rate was correlated with larger tumor size (T1-T2 versus T3; P = 0.045) and positive clinical nodal status (N0 versus N1-N2; P = 0.003) before NAC. In particular, the false-negative rate was 0% (0/29) in N0 patients and 29.6% (8/27) in N1-N2 patients. Clinical and pathological responses to NAC did not influence the accuracy of SLN biopsy. Conclusion Our results show that clinical nodal status is the main clinicopathological factor influencing the false-negative rate of SLN biopsy after NAC for breast cancer. SLN biopsy after NAC can predict the ALN status with a high accuracy in patients who are clinically lymph node negative at presentation.     

Axillary Reduction Mammaplasty—Yhelda Felício's Technique

The problem most common to the majority of mammary reductions is patient dissatisfaction due to breast scarring or lateralization of the breast. Many of these complications can be avoided by use of an axillary approach for correction of breast ptosis via the axillary skin incisions.     

Ultrasound-Assisted Lipoplasty (UAL) in Breast Surgery

Breast surgery has evolved significantly since the increased demand for reduced scars led to the development of minimal incision techniques. Ultrasound-assisted lipoplasty (UAL) presents important advantages when compared to traditional liposuction, such as preservation of connective structures and significant skin retraction capability. Other factors such as a favorable side-effect profile, satisfactory aesthetic results, and virtually inconspicuous scars have led us to utilize UAL in virtually all of the different breast surgery modalities carried out in our practice. Important aspects of patient selection, markings, surgical technique, and postoperative care are outlined. Ultrasonic energy is applied through superficial tunnels that lie radial to the mammary cone, with preservation of elements such as the areola, mammary ducts, and the central part of the breast's base which contains the perforators that supply the gland. Deep treatment should be applied onto adipose tissue regions and should preferably be performed in the peripheral and subcutaneous layers of the breast, with conservation of the central glandular cone to ensure maintenance of anterior projection. In selected cases, UAL is a valuable adjunct to procedures such as symmetrization, reduction mammaplasty, and breast reconstruction, permitting both volume reduction and shaping through three-dimensional retraction of connective tissue and skin. The excellent preliminary results support new indications and future developments of the technique.     

Blood Loss and Hematological Recovery Following Reduction Mammaplasty and Dermolipectomy: A Prospective Study

A study was made to assess the impact of surgery on the hematological status and postoperative hematological recovery of 75 consecutive patients undergoing either reduction mammaplasty or dermolipectomy. Blood losses were estimated the morning after surgery, measuring decreases in hemoglobin level and hematocrit, while postoperative recovery was evaluated in terms of hemoglobin level and hematocrit at 10 weeks. The postoperative hemoglobin decrease was 2.69 g%, and the hematocrit dropped 7.25%. By 10 weeks, however, the patients had recovered their preoperative values. We found no significant differences in the evolution of hemoglobin level and hematocrit during the study between reduction mammaplasty and dermolipectomy patients. A significant positive correlation between surgical piece weight and postoperative reduction in hemoglobin concentration and hematocrit was observed. Conversely, at 10 weeks, a significant but negative correlation between surgical specimen weight and hemoglobin concentration and hematocrit was recorded. The anticipated weight of the surgical piece could thus be used as a predictor of intraoperative blood loss and of the speed of postoperative recovery. Since patients with surgical resection of >3 kg remained anemic at 10 weeks, oral iron supplements could benefit this subset of patients.     

Effect of Ultrasonic Assisted Lipectomy (UAL) on Breast Tissue: Histological Findings

As the use of ultrasound-assisted liposuction (UAL) increases, the technique grows more popular in breast surgery, especially in reduction mammaplasty and treatment of gynecomastia. The aim of our study was to investigate the effect of UAL on breast tissue using histological examinations, and analyze the effect of this technique on a cellular level. Biopsies from 10 patients undergoing ultrasonically assisted lipectomy prior to classic reduction mammaplasty were taken from the treated areas of the breast. Biopsies were fixed in formalin and embedded in paraffin. Sections were stained with hematoxilin-eosin, and analyzed for defective adipocytes, and the effects of UAL on breast tissue. Untreated breast tissue and breast tissue that had been treated only with conventional aspiration lipectomy served as controls. Sections were analyzed using light microscopy. Compared to the breast tissue treated only with conventional lipectomy, a stronger destruction of the cellular structure of adipocytes could be detected. The destruction was visible even in areas more distant from the aspiration channel. In contrast, the breast tissue was mostly intact, no signs of ultrasonic-induced cellular destruction were visible. The glandular structure was kept intact. Beside the direct mechanical destruction by the probe and the canula, no further alterations of the cellular integrity of the glandular parts were visible. In conclusion our results indicates that UAL is also a safe technique for use in breast surgery. Besides easy handling and improved modelling, the destructive effect of the ultrasound does not include the glandular breast tissue.     

An Analysis of Breast Sensation Following Inferior Pedicle Mammaplasty and the Effect of the Volume of Resected Tissue

The aim of our study was to evaluate if the amount of resected breast tissue has an influence on breast sensitivity after inferior pedicle mammaplasty. In the prospective study, 15 patients (30 breasts) were divided into two groups: group I (less than 400 g resection) and group II (more than 400 g resection). Preoperatively and six months postoperatively a touch test (Semmes-Weinstein monofilaments) and temperature (warm and cold) tests were performed. The study showed that all patients had increased touch sensitivity six months after inferior pedicle mammaplasty regardless of the amount of resection. In group I an average of 65% and in group II an average of 83% retained sensitivity for temperature postoperatively. These results suggests that this mammaplasty technique preserves intercostal nerves within the inferior pedicle and reliefs chronic nerve traction injury and improves thereby breast sensibility.     

Pectoralis Major Muscle Flap: A New Support Approach to Mammaplasty, Personal Technique

Despite the significant evolution of mammaplasty techniques, some undesirable changes on the operated breasts result in evident dissatisfaction for both patients and doctors. The main reason is that the breast has a tendency to resume its previous shape months after the operation. In pursuit of a procedure that would avoid this untoward morphologic evolution, we set to work on the development of a new approach of broad fixation to maintain the breast shape and to avoid ptosis by using the inferior third of the pectoralis major muscle. The authors report their experience with 46 consecutive cases of breast reduction and mastopexy operated between March 1994 and November 1995, studying the surgical procedure employed, its advantages, limitations, and possible complications.     

Nummular Nipple Hypertrophy and Repair as Part of an Aesthetic Nipple-Areola Unit

The author suggests that an aesthetically pleasing ratio between nipple and areola diameter exists which should always be taken in consideration during nipple and areola reconstruction. In a study of 40 nipple–areola complexes of 20 healthy, nulliparous, Caucasian female volunteers with a mean age of 25.5 years, the average nipple diameter measured 28% of the areola diameter, that is, a ratio of 1:3.6. A hitherto undescribed form of macrothelia is presented in which the nipple width rather than the projection (length) is increased. A successful technique for reconstruction is described, based on the new method of assessing the aesthetic relations within the nipple–areola complex and known anatomy.     

Subfascial Endoscopic Transaxillary Augmentation Mammaplasty

Video endoscopy for breast hypoplasia and glabellar frown lines has been used since 1996 at our private clinic. Breast augmentation with an S-shape incision for transaxillary access is utilized to introduce the implant, in a submuscular or subglandular and, recently (since October 1998), in a subfascial location. From August 1998 through January 1999, 62 patients underwent endoscopic surgeries; 49 were submuscular, 5 subglandular, and 8 subfascial. McGhan 410, anatomical biodimensional implants 155 to 235 g, were used. We observed three cases of complications, two of them malpositioning (rotation), needing reoperation, and one hematoma, treated with drainage. Patient satisfaction was high, especially regarding the axillary incision. There have been no capsular contractions to date.