Breast Sculpturing: Overcoming the Limits of Traditional Approaches in Breast Reduction

Background  A technique based on original refinements of the vertical breast reduction was developed in our department. The aim of the technique was the safe and aggressive sculpture of an attractive breast mound with minimal scarring and long-lasting results that is easy to perform and suitable for teaching purposes in a surgical training unit. Methods  Fifty consecutive patients who were to undergo bilateral breast reduction were prospectively enrolled in the study. Accurate standard anthropometric measurements and photographs were taken preoperatively and postoperatively at 2, 6, 12, 24, and 36 months. A selective breast liposuction plus a superior pedicle breast reduction with a vertical scar skin pattern was performed in all cases. Results  Nipple lifting ranged from 5 to 14 cm; reduction of the distance between the inframammary fold and the nipple ranged from 0.5 to 7 cm; breast base width reduction ranged from 0 to 7 cm. Conclusion  This technique further contributes to vertical mammaplasty refinements, enhancing the key role of selective liposuction prior to surgical dissection of the breast. The basic principle is to convert a large breast into a middle-sized one, making vertical scar breast reduction the most appropriate technique for all cases. A thorough and selective liposuction of the breast mound reduces the breast cone base width safely and with virtually no limitations, thus breaking a taboo of traditional breast reduction techniques.     

Vertical Mammaplasty Marking Using the Key Hole Pattern

Many modifications of the vertical mammaplasty procedure used to shorten the learning curve have been described. The authors advocate marking the breasts for the vertical mammaplasty operation according to the key hole pattern. They have used inverted T techniques on the upper breast and Lejour’s vertical mammaplasty on the lower breast. A total of 14 patients who had breast hypertrophy and ptosis underwent operations with this marking modification. The amount of removed breast ranged from 285 to 875 g per breast. Hematoma, skin necrosis, skin dehiscence, loss of nipple–areola sensitivity, and distortion were not observed in these cases.     

Gigantomasty: Treatment with a Short Vertical Scar

Background During the past 15 years, reduction mammoplasty with a short vertical scar has become increasingly common in the world of plastic surgery. Still, the indication for this technique often is limited to smaller reduction weights, so that the inverted T-scar techniques have yet to be regarded as the gold standard for excessive breast hypertrophy. Methods In the authors’ department, their own modification of vertical scar reduction mammoplasty, based on the techniques of C. Lassus, G. Maillard, and M. Lejour, has been performed since 1990. During the past 10 years, the authors have used it for all breast sizes. To investigate the safety and the results for patients with very large breast volumes (gigantomasty involving at least ≥1,000 g of excised tissue per one side), this study retrospectively evaluated 25 women with a mean age of 43.1 ± 11.2 years who underwent surgery from January 2002 to June 2003. A protocol was used to record patient satisfaction and complaints and to quantify the final result objectively. Results The average resection weight for the 25 women was 1,227 ± 300 g (maximum, 2,300 g) on the right side and 1,218 ± 343 g (maximum, 2,100 g) on the left side. The sternal notch-to-nipple distance was reduced from 37.1 ± 4 cm to 23.4 ± 2.1 cm on the right side and from 37.4 ± 3.5 cm to 24 ± 2 cm on the left side. The brassiere size was reduced by about three cup sizes on the average. During an average follow-up period of 2 years (n = 15), patient satisfaction was high, with good acceptance of the breast shape and a low rate of major complications (12%). Conclusion The results suggest that the authors’ modified vertical scar technique can be used successfully for all dimensions of reduction mammoplasty regardless of breast weight.     

直线法乳房成形术的临床应用

目的介绍直线法乳房成形术(Lejour法)及其改进方法。方法按Lejour法设计手术切口,剥离乳腺组织,仅保留上部蒂营养乳头、乳晕,去除部分肥大下部及基底乳腺组织,将剩余腺体组织的乳腺基底层固定于第2、3肋水平。重新塑形乳腺组织,皮肤无张力缝合。对于部分乳房肥大明显患者可以首先抽吸脂肪,主要减少乳房腺体内、外侧及侧胸部皮下脂肪。结果采用此法矫治巨乳症、单纯乳房下垂共48例,其中辅助脂肪抽吸13例,术后乳房外形美观,术后3个月随访,3例有修整乳晕瘢痕或乳房下皱襞瘢痕。结论本术式简便易行,且远期效果好,乳房外形挺拔,可作为乳房缩小悬吊术的可行术式之一。     

Autoaugmentation Mastopexy with an Inferior-Based Pedicle

Mammaplasty for breast enhancement and correction of ptosis augmentation is described. Between 2002 and 2007, autoaugmentation mammaplasty was performed for 27 patients (age, 48 ± 7.3 years) using an inferior-based flap of deepithelialized dermoglandular tissue inserted beneath the breast parenchyma of a superior-based nipple-areolar complex pedicle. The results confirmed that autoaugmentation mammaplasty corrects ptosis while increasing the projection and apparent volume of the breast. The degree of inframammary fold (IMF) descent 6 months after surgery generally paralleled that of the nipple. The mean level of the IMF was below the mean level of the nipple. Postoperatively, the optimum distance had been largely achieved. The advantage of the technique is that it optimizes the shape and volume of the breast without the use of an implant.     

The use of a combined technique in reduction mammaplasty (inferior pyramidal and superior glandular techniques)

The management of mammary hypertrophy is a developing process. The common surgical options for reduction mammaplasty include amputation with free nipple graft as well as the bipedicled, inferior pedicle and vertical pedicle techniques. All techniques are used widely. Disadvantages of these procedures include nipple areola necrosis, insensitivity, hypopigmentation, and poor breast projection. Even with the standard modifications of the original techniques, the resultant breast and nipple may be wide and flat. The purpose of this study was to assess whether combined inferior pyramidal pedicle and superior glandular pedicle reduction mammaplasty can optimize nipple and breast projection. Attention will focus on the viability and sensation of the nipple areola complex. Nine patients with mammary hypertrophy were studied. The change in nipple position ranged from 7 to 13 cm. The amount of tissue removed from each breast ranged from 500 to 1150 g. Nipple/areola sensation was retained in all cases with the exception of one breast. Nipple/areola necrosis or hypopigmentation were not observed. Optimal central breast projection was maintained in all patients, and postoperative evaluation was carried out at 12 and 22 months. The patient satisfaction was very high.     

Intraoperative Modification of Pitanguy Technique of Reduction Mammaplasty for Elevation of the Nipple�CAreola Complex in Case of Severe Breast Ptosis

Background  

The Pitanguy method of reduction mammaplasty has been shown to be an anatomically safe technique in the management of the ptotic breast. However, the technique, as first described, cannot be applied in gigantomastia or severe breast ptosis cases or cases of dense parenchyma of the breast. The senior surgeon suggested an intraoperative modification of the Pitanguy method of reduction mammaplasty to make it applicable for such cases.     

Vertical Mammaplasty as Secondary Surgery After Other Techniques

Vertical mammaplasty, a technique that avoids submammary scars, has proved to be a reliable method of breast reduction because it is adaptable to most cases and produces beautiful and durable results. What about secondary cases? In the last 14 cases referred for secondary mammaplasty, at 1–19 years after their initial surgery, patients' indications were poor shape (14), visible and improperly located scars (9), excess volume (8), asymmetry of the areolas (5) or the breasts (1), insufficient volume (2), and asymmetry with reconstructed breast (2). The original scars were inverted T (10), periareolar (2), oblique (1) or vertical (1). Their appearance was a concern for nine patients. All patients but one, who had long submammary scars surrounded by heavy stitch marks requiring correction, could benefit from a vertical mammaplasty. This avoided long months of scar redness and visibility along the submammary folds. Good symmetry and shape could be obtained in all cases by adjusting the markings to the needs. Liposuction was a great help to remove volume without endangering the blood supply of the areolas, possibly transforming reductions in simple mastopexies.     

Refinements of Vertical Scar Mammaplasty: Circumvertical Skin Excision Design With Limited Inferior Pole Subdermal Undermining and Liposculpture of the Inframammary Crease

Vertical scar mammaplasty, first described by Lötsch in 1923 and Dartigues in 1924 for mastopexy, was extended later to breast reduction by Arié in 1957. It was otherwise lost to surgical history until Lassus began experimenting with it in 1964. It then was extended by Marchac and de Olarte, finally to be popularized by Lejour. Despite initial skepticism, vertical reduction mammaplasty is becoming increasingly popular in recent years because it best incorporates the two concepts of minimal scarring and a satisfactory breast shape. At the moment, vertical scar techniques seem to be more popular in Europe than in the United States. A recent survey, however, has demonstrated that even in the United States, it has surpassed the rate of inverted T-scar breast reductions. The technique, however, is not without major drawbacks, such as long vertical scars extending below the inframammary crease and excessive skin gathering and “dog-ear” at the lower end of the scar that may require long periods for resolution, causing extreme distress to patients and surgeons alike. Efforts are being made to minimize these complications and make the procedure more user-friendly either by modifying it or by replacing it with an alternative that retains the same advantages. Although conceptually opposed to the standard vertical design, the circumvertical modification probably is the most important maneuver for shortening vertical scars. Residual dog-ears often are excised, resulting in a short transverse scar (inverted T- or L-scar). The authors describe limited subdermal undermining of the skin at the inferior edge of the vertical incisions with liposculpture of the inframammary crease, avoiding scar extension altogether. Simplified circumvertical drawing that uses the familiar Wise pattern also is described.     

Vertical Scar with the Bipedicle Technique: A Modified Procedure for Breast Reduction and Mastopexy

Background Reduction mammaplasty and mastopexy are commonly performed aesthetic procedures. One such procedure, the vertical scar technique, has gained popularity in recent years, and various types of pedicles have been designed and associated with it. The vertical scar with the bipedicle technique is one such combination that ensures nipple safety and minimizes scarring, with a good aesthetic result. Method With the vertical scar marked on the outside and the bipedicle flap marked on the inside, the procedure was performed for 23 patients. Results Between 2004 and 2006, 17 reduction mammoplasties and 6 mastopexies were performed. The average tissue resection was 360 g, and the average blood loss was 70 g. The average preoperative nipple–areolar complex was 28 cm (range, 23–41 cm). Good results were achieved for the majority of the patients, with no nipple loss or loss of sensation. Conclusion The vertical scar bipedicle technique, a combination that meets the requirement of minimum scarring and a robust blood supply to the nipple–areolar complex, is a suitable option for selected reduction mammaplasty and mastopexy.     

垂直切口乳房缩小术

目的　探讨应用垂直切口巨乳缩小术以减少术后瘢痕的方法与体会。方法　采用Lejour手术设计 ,切除乳房下方的皮肤、腺体 ,乳头乳晕以上方真皮腺体组织蒂转移提高到正常位置 ,进行乳房塑形 ,术后仅留有垂直瘢痕。结果　采用垂直切口巨乳缩小术治疗 2 4例 ,手术效果满意。 1例术后 6个月切口下端局部修整残留的“猫耳朵”。 1例单侧乳头乳晕完全坏死。结论　垂直切口巨乳缩小术疗效良好 ,术后瘢痕细小 ,乳房形态良好。     

The supero-medial dermal-glandular pedicle mastoplasty with Wise pattern: an easy technique with a shorten learning curve. is it the gold standard for severe gigantomastia?

The Authors present their experience using the supero-medial dermal-glandular pedicle technique with a "Wise pattern" for severe gigantomastia, which they found easy to perform and to explain when teaching and they recommend its use especially for junior who are at the beginning of their experience with breast reduction. Although the preferred technique in our practice is the vertical scar mammaplasty with the superomedial pedicle according to Hall-Findlay, we believe the extension of the "Wise pattern" is necessary for severe gigantomastia (> 1200 g). From January 2005 to April 2008 50 breast reductions were carried out by the Authors using the supero-medial pedicle technique with a Wise pattern skin resection. The mean age was 40 years (range 20 to 65), mean body mass index was 28 (range 25 to 32) and mean weight of breast tissue removed was 1450 g per side (range 1120 to 2200). A maximum follow-up of 3 years was carried out. The complications were minor and self-limiting. The revision rate was very low (2%) compared to the other techniques. The supero-medial pedicle technique is a safe and reliable procedure in patients with severe gigantomastia and its versatility allows to be performed on all types of breasts regardless of size or degree of ptosis.     

A False-Positive Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) Imaging Result for a Patient After Augmentation Mammaplasty

Background  Various materials and methods have been used for augmentation mammaplasty since it was first performed in Japan in the late 1940s. Although augmentation mammaplasty is not associated with an increased risk of breast cancer, a number of studies have reported that breast implants, or subsequent changes around these foreign substances, can affect images made by mammography, CT, or MRI during breast cancer screening. A method that is increasingly being used to detect cancer is positron emission tomography (PET). Methods  To determine the effect of augmentation mammaplasty on PET imaging, we subjected ten women who had previously undergone augmentation mammaplasty to PET imaging as well as other imaging methods. We also measured tumor markers and performed pathologic studies. Results  The histologic analyses failed to detect any cases of malignancy. We assess the efficacy of PET for detecting breast cancer in women who had undergone augmentation mammaplasty and describe the features of the PET images of these women. Finally, we discuss future research objectives in relation to PET-based screening for breast cancer. Conclusion  It is important to identify an imaging methodology that improves the detection of breast cancer in patients with a previous mammaplasty. We show here that FDG-PET may improve breast cancer detection after mammaplasty.     

Vertical scar reduction mammaplasty as a standard procedure – experiences in the introduction and validation of a modified reduction technique

Based on experiences with a modified vertical scar reduction mammaplasty technique over a 5-year-period, this article discusses the results obtained and complications encountered with this technique. From 1991 to 1995, 628 reduction procedures were performed using a single vertical scar technique in 228 patients. The percentage of procedures with the new technique increased from 17.4% in 1991 to 89% in 1995. There was an increase in the mean reduction weight from 528 to 1313 g (mean 1028 g, 260–3300 g). Sixty-eight percent of patients (n=154) underwent follow-up examinations at 3 and 12 months postoperatively. The complication rate including perioperative and post-discharge problems was 40.2%. Complications occurring as a result of the procedure included an excessively long vertical scar (13%), skin redundancy in the submammary fold (15%) and wound dehiscences (10%). Minor corrective surgery was carried out in 38 patients. The modified vertical scar reduction mammaplasty technique may be considered a safe standard procedure for almost all breast sizes. Received: 23 June 1997 / Accepted: 2 February 1998     

Short scar reduction mammaplasty in the bariatric patient

Reduction mammaplasty may be necessary even after massive weight loss. Patients typically present with unfavorable breast features such as significant loss of upper pole volume, inelastic skin, and severe ptosis. The most common approach in the United States has been the Wise-pattern inferior pedicle technique, emphasizing skin excision. This report presents the short scar vertical reduction mammaplasty approach for the bariatric patient population. It aims to demonstrate improved outcomes with less scar burden. The study included 15 women (n = 29 breast reductions) with mean age of 41.8 years. All the patients had undergone gastric bypass surgery, with mean weight loss of 109 pounds and mean body mass index of 33.3 kg/m(2). A modified superomedial pedicle vertical mammaplasty technique was used. New nipple position was placed lower than the inframammary fold in accordance with vertical lack of upper pole fullness. Suction-assisted lipectomy was used to contour the inferior pole of the breast before glandular resection. A full-thickness superomedial pedicle and median incision of the upper pole maximized pedicle safety. The mean breast resection was 605 g on the right side (range, 352-945) and 592 g on the left side (range, 360-908). Patient satisfaction was high, with pleasing and stable breast shape at long-term, and a mean patient-related aesthetic ranking of 4.3 of 5.0. No major complications were noted. It is shown that superomedial pedicle vertical reduction mammaplasty can be an alternative approach in bariatric patients, achieving long-term pleasing and stable results with significantly decreased scar burden.     

Combination of the vertical and periareolar mammaplasty

Vertical mammaplasty has been perfected and popularized by Madeline Lejour; this technique is one of the most versatile methods of manunaplasty today. The vertical scar from the nipple areola to the submammary line is often much longer and distorted than the conventional mammaplastys. The length of the vertical scar can be reduced by 2–3 cm by combining the skin pattern of the periareolar and vertical mammaplasty. The aesthetic result can be improved by shortening the vertical scar.     

The Bivectorial Full-Thickness Superiorly Based NAC Flap: A New Option to Increase Plasticity and Decrease Tension in the Superior Pedicle Vertical Mammaplasty Technique

The standard split-thickness superior pedicle vertical mammaplasty technique sometimes suffers from tension on the nipple-areola complex (NAC). We suggest a bisected full-thickness superiorly based flap that offers two vectors for transposition within the context of superior pedicle vertical mammaplasty. The procedure increases both upper-pole fullness and projection of the breast while decreasing tension on the NAC. The surgical procedure presented contributes to a natural appearance of the breast. It should provide a useful and simple surgical option, increasing the versatility of the superior pedicle vertical mammaplasty technique.     

无垂直瘢痕的下蒂瓣法乳房缩小整形术

目的:介绍一种适用于中、重度乳房肥大的矫正术,探索乳房缩小手术的最佳术式。方法:回顾总结2001年以来对21例中、重度乳房肥大患者采用无垂直瘢痕的下蒂瓣法行乳房缩小整形术的情况,分析其效果。结果:21例患者术后双乳对称,下垂状况纠正,体积缩小,乳头乳晕感觉良好,术后瘢痕隐蔽。2例合并副乳,1例合并乳头内陷的患者同时手术切除矫正。2例乳晕表皮营养不良、部分坏死,经换药愈合。结论:无垂直瘢痕的下蒂瓣法乳房缩小整形术是治疗中、重度乳房肥大症的良好选择。     

Avoiding free nipple grafts during reduction mammaplasty in patients with gigantomastia

Excessive breast hypertrophy or gigantomastia (>2000 g excision of tissue per breast) has traditionally been approached with breast amputation and free nipple grafting during reduction mammaplasty procedures. Disadvantages of free nipple grafts include loss of sensation, poor projection, uneven nipple-areolar complex pigmentation, and loss of lactation. We report our experiences utilizing the inferior pedicle technique of reduction mammaplasty with successful preservation of the nipple-areola complex for patients with gigantomastia. Between 2001 and 2003, 15 patients (ages 19--45) were identified with gigantomastia through review of pathology and operative reports. The inferior pedicle technique was performed in all cases by the attending staff assisted by plastic surgery residents. Patients were followed regularly from 1 week up to 1 year postoperatively. All patients reported relief from the physical sequelae of breast hypertrophy. One patient experienced bilateral partial nipple desquamation; she maintained sensation throughout and healed well with moist dressings. Otherwise, there were no complications and all patients achieved satisfactory esthetic outcomes. Our results suggest that inferior pedicle technique can be successfully performed in patients with gigantomastia. Breast amputation with free nipple grafting need not be considered standard practice for this patient population. Maintaining a wider pedicle base and meticulous intraoperative handling of the pedicle may contribute to the increased viability of the nipple-areolar complex during these cases.