Breast reduction may be indicated for both physical and psychological complaints. Patients often suffer from a combination of physical and emotional problems that noticeably reduces their quality of life.
Heavy, sagging breasts can lead to chronic neck and back pain and cause painful grooving from bra straps in the shoulder area. Patients typically report previous or ongoing physiotherapy or orthopaedic treatment, which usually remains unsuccessful because it is purely symptom-oriented. Further problems can arise from painful breasts (mastodynia) and the hygiene consequences of intertrigo. In addition, psychological distress is often reported, which further restricts patients in their social environment, for example at school or during sporting activities (swimming). The positive effect of breast reduction on psychological distress has long been known and has been confirmed by studies. (Iwuagwu et al. 2006) In plastic surgery, breast reduction – reduction mammaplasty – is a good example of a procedure that belongs to both the reconstructive and the aesthetic spectrum. The aim of breast reduction is to create a breast shape that is in harmony with the existing body proportions. Certain anatomical landmarks must be taken into account, of which the inframammary line and the position of the new nipple are of particular importance.- Macromastia refers to an enlargement of the female breast gland beyond the normal range.
- Gigantomastia refers to a massive enlargement of the breast, with a resection weight of more than 1,500 g per side
Degree of ptosis according to Regnault
- Grade I NAC at the inframammary fold and above the breast contour – the glandular tissue lies behind the NAC
- Grade II NAC below the inframammary fold but above the breast contour – the glandular tissue lies behind the NAC
- Grade III NAC below the inframammary fold and forming the lowest point of the breast contour – the glandular tissue lies below the NAC
Degree of ptosis according to Bostwick/Georgiade
- Grade I NAC up to 1 cm below the inframammary fold
- Grade II NAC 1–3 cm below the inframammary fold
- Grade III NAC >3 cm below the inframammary fold and forming the lowest point of the breast
Anatomy of the breast
The arterial blood supply of the breast comes from the internal mammary artery, lateral thoracic artery, thoracoacromial artery and lateral perforators from the intercostal arteries. The nipple–areola complex is supplied from all of these arterial territories, so that various pedicles are possible in breast reconstruction (superior, inferior, medial, lateral, central pedicle). The main supply (60%) comes from perforators of the internal mammary artery (superior, medial and inferior branches). Venous drainage occurs via 2 anatomically separate systems, a superficial, subdermal venous network and a deep venous system. The sensory innervation of the nipple–areola complex comes from anterior and lateral branches of the 3rd–5th intercostal nerves, with the branches of the 4th intercostal nerve being the most dominant. This nerve usually runs for a long distance beneath the fascia of the pectoralis muscle before perforating centrally in the area of the nipple–areola complex. Careful dissection preserving the pectoral fascia is therefore important in all reduction techniques.
Preparing for surgery
In addition to the general medical and medication history, a complete physical examination is carried out. Particular importance is attached to the personal and family history regarding the presence of malignancies. In particular, additional risk factors such as smoking, coagulation disorders, use of contraceptives or medicines affecting blood flow must be clarified before surgery. Stopping smoking for at least 2 weeks before surgery is strongly recommended before all aesthetic procedures!!! During the outpatient consultation, advice is also given on the timing of the operation. In obese patients who are planning to lose weight, breast reduction should only be carried out once a stable normal weight has been reached. Ideally, patients should be able to maintain this weight for at least 12 months in order to reduce the perioperative risk and not jeopardise the surgical result.Reduction mammaplasty may only be carried out when body weight is stable. Optimal BMI <28 kg/m2!!!
If family planning is not yet complete and the patient wishes to preserve the ability to breastfeed, the planned breast reduction should only be carried out after any wish for children has been fulfilled. In adolescent patients, changes to the shape of the breast should only be carried out after glandular growth has been completed. Exceptions are massive gigantomastia with correspondingly understandable distress. Regardless of age, all patients should have a mammogram before breast-reshaping procedures; it should not be older than 3 months at the time of surgery.
Surgical techniques
Practically all surgical procedures described in recent decades (McKissock 1972, Pitanguy 1962, Skoog 1963, Strömbeck 1983) result in a scar around the cranially repositioned nipple, extending 4–6 cm downwards and then running transversely in the inframammary line (inverted-T technique). In certain cases, very good results can also be achieved with a purely vertical scar (Lejour 1994, Lassus 1970, Hall-Findlay 1999). Inverted-T technique according to Höhler – breast reduction according to Strömbeck If a significant reduction in breast volume is planned, the Höhler reduction technique can be used. This method was later modified by Pitanguy and Strömbeck and involves a cranial nipple pedicle with a T-shaped scar. Periareolar technique With this method, the desired tightening and lifting of the breast can, in suitable cases, be achieved solely through an incision at the border of the areola, and thus with the least scarring. Scar-sparing breast lift according to Lejour As the success of this operation depends on the retraction capacity of the skin, the technique should mainly be used in young patients with elastic skin. A disadvantage of this procedure is the long persistence of skin pleating (puckering) in the area of the scar. This phenomenon must be discussed in detail during the informed consent consultation. This procedure is suitable for patients who mainly want correction of skin laxity and ptosis of the breasts and only a small reduction in volume.Complications after reduction mammaplasty
- Haematoma or seroma formation
- Altered sensation in the nipple–areola complex
- Necrosis of the nipple–areola complex
- Fat necrosis
- Asymmetry
- Excess skin/soft tissue: dog ears
- Hypertrophic scarring
- Wound healing problems
- Loss of the ability to breastfeed
