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