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Reduction mammoplasty in teenage patients

Hildegunde Piza-Katzer
1 July, 2006  

Hildegunde Piza-Katzer
MD PhD
Chairman
Department of
Plastic and
Reconstructive Surgery
Innsbruck Medical University
Austria
T: +43 512 504 2730
E: Hildegunde.Piza@uibk.ac.at

Reduction mammoplasty is a surgical intervention, the aim of  which is to reduce the size of overly large breasts  (macromastia) to enable a better life for the patient both  physically and emotionally. Excessively large breasts are  not necessarily associated with obesity but nevertheless  make several activities, including swimming, sports and  doing exercises, difficult. Symptoms such as back, neck and  shoulder pain, grooving from bra straps, poor posture and  skin irritation are some of the physical disadvantages  associated with macromastia. It might even be difficult for  the person involved to stand up straight without pain, while  getting properly fitting clothes is a nightmare. Added to  this is the social embarrassment and the psychosocial  problems, such as depression, poor body image and social  avoidance, since large breasts provoke teasing and ridicule  from others – this is especially true of teenagers. Several  studies have confirmed that breast reduction surgery results  in significant improvement in physical and emotional wellbeing.

Diagnosis
Juvenile gigantomastia is a rare benign disorder of the  female breast in which one or both breasts undergo rapid  enlargement in adolescence. The most common differential  diagnoses are juvenile fibroadenoma, virginal hypertrophy  and cystosarcoma phyllodes, thought to result from  hypersensitivity of breast tissue to normal levels of  gonadal hormones. Malignant tumours, such as lymphomas and  sarcomas, are extremely rare in the prepubertal and pubertal  breast. In the massive enlargement of both breasts a  bilateral reduction mammoplasty with free nipple grafts is  mandatory.

Breast development begins to take place in most girls around  the age of 10–11. Breast development may, however, be  asymmetric – a fact that becomes noticeable when they begin  to mature. One of the breasts may be much larger than the  other, the opposite one being of normal size or even small  in relation to the general body frame of the individual.

Breast asymmetry might or might not be associated with  hypertrophy, but in any case represents a problem in teenage  patients. Asymmetric breasts per se do not usually present  medical problems, unless they are associated with  hypertrophy. Though no medical indications for restoration  of symmetry are given, breast size discrepancies often have  a severe impact on quality of life resulting from social  ridicule and disturbed body image and therefore need to be  addressed. The location and extent of scars after reduction  mammaplasty represents an aesthetic problem in this group of  patients, so a technique must be chosen that leaves behind a  hardly visible scar.

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Initial consultation
The initial consultation with the plastic surgeon is  crucial. The surgeon must be sensitive to the fears and  anxiety of the patients and encourage them to formulate  their particular concerns and wishes. Attentive listening  helps the surgeon to detect unrealistic expectations and  disturbed psychological states, if present. Details about  the appropriate time for surgery, the various methods of  operation, the risks, the possible complications and, above  all, the unavoidable scars to be expected must be explained  to patients in a language that they are able to understand.  Being offered an opportunity to look at pictures before and  after reduction surgery helps them to get a clearer idea of  what they can expect from the operation. Often, the surgeon  can help the patients further in overcoming their fears by  encouraging them to talk to others who have previously  undergone similar procedures.

Reduction mammoplasty
Many different methods have been described for reduction  mammaplasty; however, no single method is applicable in all  cases. In most techniques, in addition to the resection of  the breast parenchyma, the skin envelope around the breast  is also resected and the nipple, along with the areola, is  transposed to a higher position. The techniques also differ  in the type of pedicled flaps used, the length of the scars  and whether additionally mastopexy of the rest of the  parenchyma is performed. The nipple–areola complex is  pedicled on a section of the dermis. The glandular tissue,  together with the nipple–areola complex, can have a  bilateral horizontal, unilateral, cranial vertical or caudal  pedicle.

The length of the scar has also been subjected to several  modifications. With his incision technique Dufourmentel  attempted to avoid the caudal horizontal scar in the medial  part of the breast, whereas Peixoto and Basile aimed at a  shortened inframammary scar. The inframammary scar was  completely avoided by Lassus in his reduction mammaplasty.  However, this method is applicable only in cases of  mild-to-moderate breast hypertrophy. Lejour modified this  technique so that it can be used in the reduction of even  very large breasts. In all the above-described methods, the  nipple–areola complex is circumferentially incised and moved  upward for repositioning so that there is always a  periareolar scar. Each of these methods must be analysed in  terms of their possible postoperative complications and  long-term results. Inadequate vascular supply, wound healing  disturbances on the skin, fatty tissue, the nipple–areola  complex, infection and haematoma are some of the associated  problems in this connection.Unsatisfactory, long-term  results can also be consequences of hypertrophic scars,  asymmetry, excess reduction or too little reduction.

The teenage patient
Reduction mammoplasty in teenagers is a particularly  challenging intervention that requires a specific technique.  Preoperatively, the incision marks are made with the patient  standing. The vertical breast axis is marked. The incision  line is fixed and marked on the submammary crease. The  extent of reduction is determined by calculating the height  of the disk and marked. In case of bilateral hypertrophic  breasts, this procedure is carried out on both breasts.

Depending on the distance between the submammary crease and  the lower margin of the areola, a transverse oval-shaped  skin piece of a few centimetres is resected. The glandular  tissue is dissected away from the central part of the  pectoral fascia, taking care not to injure the segmental  nerves and blood vessels running into the breast laterally  and medially. The perforating branches of the internal  thoracic artery, particularly at the level of the fourth  intercostal rib in the medial part and the branches of the  lateral thoracic artery in the lateral part of the breast,  are retained. Thereafter, a disk-shaped breast tissue  segment ventral to the pectoral fascia is resected, and the  remaining breast parenchyma is fixed to the pectoral fascia  with between three and five nonabsorbable interrupted  sutures. Redon drains are inserted in the resection cavity  and removed 24 hours after the operation in most cases. The  breast reduced in this fashion is fixed to the chest wall  with a special tape bandage, which is applied relatively  tightly and helps support the natural retraction ability of  the youthful skin. This is left on for 3–4 weeks. From then  on, a support bra is prescribed, which the patient has to  wear day and night for six weeks.

Conclusion
The young breast consists predominantly of firm connective  tissue in which the breast parenchyma is embedded. The  elastic connective tissue is responsible for the firmness of  breasts in young women. Our operative technique uses the  form-shaping and form-retaining effect of the elastic  youthful skin. If the skin is capable of retraction, it fits  snugly around the reduced breast after resection of fatty  and glandular tissue, and the nipple–areola adapts to the  new size by virtue of this retraction. This is made possible  because of the availability of elastic fibres parallel with  the retraction ability of the skin.

The new surgical technique consists of a submammary incision  that eliminates the periareolar and the subareolar scars, a  disk-shaped tissue resection, maintenance of segmental  innervation and vascularity, followed by mastopexy and  postoperative fixing of the breast with the help of a tape  bandage. A further advantage of this method is that the  natural form of the breast is maintained after resection.

Acknowledgement
I would like to thank Rajam Csordas-Iyer for critical reading of the typescript and editorial assistance.