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Breast Reduction, Liposuction Only
Article Last Updated: Oct 5, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Francesca Romana Grippaudo, MD, Assistant Professor, Department of Plastic Surgery, University of Rome Policlinico Umberto I, Italy
Coauthor(s):
Daniel Christopher Kennedy, MBBS, FRACS, Consultant Surgeon, Unit Head Supervisor of Surgical Training, Department of Plastic and Reconstructive Surgery, Mater Public Hospital; Director of Medical Services, Pacific Day Surgery
Editors: Geoffrey L Robb, MD, Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery
Author and Editor Disclosure
Synonyms and related keywords:
breast reduction, suction mammaplasty, liposuction-only mammaplasty, breast liposuction
Traditional methods of breast reduction involve remodeling the breast mound based on an inferior, superior, or central pedicle and then trimming and redraping the skin over the new shape. Unfortunately, these techniques necessitate long scars. Minimizing scars in breast surgery has been an important goal in the previous 2 decades, with many techniques developed specifically for this purpose. Among them is round block mammaplasty, described by Benelli in 1990, which produces only a periareolar scar. In 1987, Lassus modified a technique described in the mid 1960s, producing a periareolar and vertical scar. In the late 1980s, Lejour applied suction lipectomy as an adjuvant to surgical resection in female macromastia. Liposuction is one of the most commonly performed procedures in plastic surgery and has been used safely in many body regions. Several authors have reported on the safety and efficacy of suction lipectomy, power-assisted liposuction, and ultrasound-assisted lipoplasty in gynecomastia. In 1991, Matarasso and Courtiss described their results using suction mammaplasty to reduce moderate breast hypertrophy in the absence of ptosis. In 1993, Williams suggested liposuction of the breast to treat a unilateral hypertrophy in an adolescent breast maldevelopment. Skin retraction secondary to scarring in the superficial plane where traditional or superficial liposuction is performed is a well-known phenomenon; a controlled iatrogenic tightening of the skin envelope is produced. In 1997, the authors reported their experience in extending the indications to liposuction of the female breast in selected patients, even in large breast hypertrophy (resection >800 g). Others have reported on breast reduction in females by liposuction-assisted procedures. In 2004, Rohrich and colleagues reported that liposuction-only breast reduction has become one of the current techniques for breast reduction, with satisfactory results for both surgeons and patients.
Problem
Female breast hypertrophy or macromastia is a condition of abnormal enlargement of the breast tissue in excess of the normal proportion. This condition may be caused by gland hypertrophy, excessive fatty tissue, or a combination of both. It varies in severity from mild (<300 g) to moderate (300-800 g) to severe (>800 g). Macromastia can be unilateral or bilateral and can occur in combination with ptosis, a term used when the nipple has descended below the inframammary crease.
Etiology
Large breasts frequently develop during pubertal breast development but also occur after pregnancy, weight gain at any age, or menopause.
Macromastia typically is caused by fat hypertrophy rather than glandular hypertrophy. Many females are destined genetically to have large breasts, which often is aggravated by pregnancy or weight gain. Iatrogenic causes include asymmetry following a mastectomy or lumpectomy. Rarely, a young patient may experience virginal mammary hypertrophy resulting in massive breast hypertrophy and a high recurrence rate following a reduction procedure.
Clinical
The typical patient presents with back pain, neck pain, breast pain, embarrassment, difficulty with sports, and clothing limitations. Those with more ptotic breasts develop intertrigo. Poor posture is common, and grooving of the shoulder from the force of the bra strap may occur. The patient may be overweight.
Breast liposuction is indicated when a minor-to-moderate reduction is requested and no ptosis correction is required.
Other indications include the following:
- Selected women needing larger reduction who do not want the scar associated with an open reduction or loss of sensation in their breasts and are willing to accept some ptosis
- As a secondary mammaplasty procedure rather than an open revision
- For asymmetry up to 1 cup size
- In young patients with virginal hypertrophy, a condition with a high recurrence rate, as a temporary procedure before the end of the growth phase
The female breast normally grows during puberty under the influence of estrogen and progesterone. It is formed by 15-20 lobules of glandular tissue, each drained by a lactiferous duct. Each duct has an opening on the nipple. These lobules constitute the mammary gland and are interspersed with fat lobules.
This fat tissue confers the rounded contour and most of the bulk of the breast (approaching 90%), except during pregnancy and lactation.
The abundant blood supply to the breast comes from perforators from the internal thoracic artery, external thoracic artery, thoracodorsal artery, and the third to fifth intercostal arteries.
Lateral and anterior cutaneous branches of the second to sixth intercostal nerves supply innervation of the breast. The third and fourth intercostal nerves most frequently innervate the nipple, but variations occur.
Any pattern of breast reduction involving parenchymal excision may disrupt nipple-areola sensation.
Mammography demonstrating breast hypertrophy to be mostly glandular contraindicates this procedure.
Liposuction reduction mammaplasty is contraindicated in any female with mammographic findings that raise suspicion.
Presence of ptosis and poor skin condition with little tissue elasticity also are contraindications to this procedure.
Lab Studies
- Obtain a CBC count to obtain a hematocrit and a platelet count.
- Obtain prothrombin time and activated partial thromboplastin time to check for a coagulopathy when clinical suspicion exists.
- Blood sugar should be in the normal range to avoid delayed healing or susceptibility to infections; check as clinically indicated
Imaging Studies
- An ultrasound scan of both breasts or a mammogram is mandatory to evaluate the percentage of fat tissue in the breast and hence determine eligibility for the procedure.
- Sensitivity of mammograms in assessing the glandular-fat tissue ratio in the breast is better than that of ultrasound scan but possibly not as effective as MRI scan (see Image 6).
- Obtain a chest x-ray if indicated by examination findings or patient history.
Other Tests
- Obtain photographic documentation to provide to the insurance company for authorization, for comparison of before and after photos to help the patient appreciate the change, and as medicolegal documentation for the surgeon in the event of litigation.
- Obtain an ECG as per anesthesia or operating room guidelines.
Histologic Findings
The aspirate can be sent for pathologic examination to exclude carcinoma or other atypia.
Medical Therapy
No medical therapy is available for breast hypertrophy. A reduction diet is advised for overweight patients.
Surgical Therapy
Reduction mammaplasty is the only known method of diminishing the size of the breast. It can be achieved with "open" techniques or in selected patients with liposuction only.
Preoperative Details
- Evaluate skin elasticity and the degree of ptosis during the consultation.
- Inform the patient about possible alternatives to reduce the hypertrophic breast and correct associated ptosis. Discuss open reduction techniques with parenchymal removal and skin resection as well as the related sequelae (ie, scars, possible loss of sensation, possible impairment to lactation).
- Discuss possible complications and give the patient the opportunity to view pictures of average results of the described procedures. Answer all questions to give the patient realistic expectations.
- Inform patients that should suction alone fail, a secondary mammaplasty procedure can be performed subsequently.
- Breast liposuction can be a day hospital procedure or an overnight procedure, depending on the amount of fat tissue to be removed and the health or preference of the patient. It usually is performed under general anesthesia.
- With the patient sitting fully erect, record the distance between the jugular notch and the nipple and from the nipple to the inframammary fold.
- Record the presence of asymmetry.
- No preoperative markings are required.
- Position the patient on the operating table in a supine position. The arms are abducted to fully expose the breasts.
Intraoperative Details
Infiltrate a solution in the deep and superficial plane of the breast. It is prepared freshly as follows:
- Plain 0.5% bupivacaine (Marcaine), 20 mL
- Plain lidocaine 2%, 20 mL
- Epinephrine, 1:1,000,000-1:500,000 (1-2 mg) in 1 L of normal saline solution
Surgical details
- Make a stab incision just above the lateral aspect of the inframammary fold (see Image 1).
- In very large breasts, make a supplementary incision just above the medial aspect of the inframammary fold. This placement permits the surgeon the opportunity of conversion into a standard inferior pedicle reduction in the event of inadequate results after the lipoaspiration.
- Perform pretunneling using the same blunt-tipped multihole cannula used to deliver the solution.
- Begin infiltration in the deep plane and complete it superficially. Use an intravenous pressure bag to hasten the procedure. Widely infiltrate all the breast area with 800-1000 mL of fluid until the tissues become firm (see Image 2).
- To achieve good vasoconstriction, wait 15 minutes before starting the procedure.
- Use a blunt 4-mm cannula connected either to a medical grade vacuum device or to a syringe to suction the fat with fan-shaped movements, starting in the deep plane and ending superficially.
- The material suctioned from the breast appears as a yellow, fatty, bloodless fluid and is removed easily (see Image 7).
- Stop the suction when the goal aspirate is reached or an unacceptably bloody aspirate is obtained.
- At the end of the procedure, use a blunt 3-mm cannula that is not connected to a suction device to undermine the superficial layer of fat. This undermining is performed mostly in the medial and lateral upper areas of the breast. The purpose of this maneuver is to stimulate a controlled scar retraction to correct ptosis.
- The procedure ends with a moulding dressing using elastic foam tape (see Image 5).
Postoperative Details
- Recovery is quick, with most patients returning to everyday activities on the second day.
- Patients are required to undergo a postoperative check at day 3 when the dressing is changed, and they are asked to wear a brassiere for 30 days.
Follow-up
- Discharge the patient the same day or the day after surgery.
- Instruct patients to shower from the third day postoperatively and encourage them to resume normal activities after the third day postoperatively.
- Inspect the wounds after 1 week on an outpatient basis.
- During the first week, the patient wears a crop top bra continuously, later exchanged for a normal support bra, which is worn continuously for at least 2 months. Make clear to every patient the importance of the moulding action obtained from wearing a support bra.
- Except in very young patients in whom radiation is an issue, obtain a baseline postoperative mammogram in all patients 6 months following surgery to delineate changes that are due to surgery alone.
Early complications include the following:
- Infections, which may require antibiotic therapy
- Hematoma, which may require prompt drainage
Late complications include an unsatisfactory volume reduction, requiring a secondary revision.
Liposuction reduction mammaplasty has proved to be an acceptable and satisfactory technique for a select group of patients. The procedure usually is well tolerated and the recovery much shorter than with open reduction mammaplasty.
Moskovitz' 2004 study investigating the outcome of liposuction-only breast reduction showed that the average time for patients to resume work is less than a week and to resume full exercise is 2 weeks, a much shorter time compared to that of other reduction mammaplasty techniques.
The breast usually is edematous and bruised in the immediate postoperative period.
As with other liposuction procedures, the final results are best evaluated after 6 months, although edema usually subsides 2-3 weeks postoperatively.
To date, no instance of tissue necrosis has been reported. Alteration of nipple sensation has been reported only rarely.
Long-term satisfaction rate generally is high, provided that the indications for this technique are respected with proper patient selection.
The situation in which the patient, happy with the scarless outcome, refuses a secondary procedure proposed by the surgeon to correct a residual ptosis of the breast or for a further reduction is not unusual.
Ultrasonic liposuction (UAL) of the female breast, proposed by some authors as an effective procedure, still remains a controversial topic because of the theoretical effects of "soft radiation." Traditional liposuction methods of the female breast do not have this possible drawback.
A 2003 investigation by Di Giuseppe showed no evidence of a suspect mass or calcifications in a group of patients treated with UAL of the breast and evaluated with mammographic studies during a 4-year follow-up period.
In 2005, Brauman warned of the change in breast density occurring after liposuction, claiming that breast cancer is more difficult to detect in a denser breast. Moskovitz answered this criticism with the observation that a change in breast density is a common finding after any reduction mammaplasty.
Whether to send the material aspirated in a liposuction mammaplasty to a pathologist for examination is an open question.
After an open reduction mammaplasty, the removed tissue is routinely sent to the pathologist for examination. After a breast liposuction, it is possible for the pathologist to examine the aspirated material.
Several studies have demonstrated this material to be only fat in up to 99% of patients. In the few patients in whom breast parenchyma cells were found, determining the location in the breast was impossible. For this reason, obtaining a preoperative mammogram is mandatory, not only to screen for the patient's eligibility for the procedure but also to detect evidence of cancer.
For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Liposuction.
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The skin is pierced 2 cm above the inframammary fold, in the mid line. |
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The right breast is infiltrated up to tumescence with solution; the left breast already has been infiltrated. |
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Appearance of the right breast after a liposuction of 700 mL. |
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Appearance of both breasts at the end of the procedure. The liposuction of the right breast is 700 mL; the liposuction of the left breast is 600 mL. |
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At the end of the procedure, elastic tape is used to mould the breast in the new shape and position. |
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Mammographic appearance of breast hypertrophy with a prevalence of fat tissue over glandular tissue. This mammographic image demonstrates the eligibility of the patient for liposuction of the breast to reduce the hypertrophy. |
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The material suctioned from the breast appears as a yellow, fatty, bloodless fluid. |
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A 22-year-old patient, preoperative view. Bra size is 40E. The distance from the jugular notch to the nipple is 33.5 cm on the right breast and 32 cm on the left breast. |
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| Media file 9:
Appearance 6 weeks after breast reduction by suction alone; 22-year-old patient. Preoperatively, bra size was 40E. The distance from the jugular notch to the nipple was 33.5 cm on the right breast and 32 cm on the left breast. During the procedure, 800 mL was removed from each breast. Postoperative bra size is 38C. The distance from the jugular notch to the nipple is 29 cm on the right breast and 28 cm on the left breast. |
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| Media file 10:
A 22-year-old patient, preoperative view. Bra size is 40E. The distance from the jugular notch to the nipple is 33.5 cm on the right breast and 32 cm on the left breast. |
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| Media file 11:
Appearance 6 weeks after breast reduction by suction alone; 22-year-old patient. Preoperatively, bra size was 40E. The distance from the jugular notch to the nipple was 33.5 cm on the right breast and 32 cm on the left breast. During the procedure, 800 mL was removed from each breast. Postoperative bra size is 38C. The distance from the jugular notch to the nipple is 29 cm on the right breast and 28 cm on the left breast. |
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| Media file 12:
Right lateral preoperative view; 22-year-old patient. Bra size is 40E. The distance from the jugular notch to the nipple is 33.5 cm on the right breast and 32 cm on the left breast. |
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Right lateral view 6 weeks after breast reduction by suction alone; 22-year-old patient. Preoperatively, bra size was 40E. The distance from the jugular notch to the nipple was 33.5 cm on the right breast and 32 cm on the left breast. During the procedure, 800 mL was removed from each breast. Postoperative bra size is 38C. The distance from the jugular notch to the nipple is 29 cm on the right breast and 28 cm on the left breast. |
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A 24-year-old patient, preoperative view. Preoperative bra size is 36DD. The distance from the jugular notch to the nipple is 25.5 cm on the right breast and 24.5 cm on the left breast. |
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A 24-year-old patient, view 6 weeks postoperatively. Preoperative bra size was 36DD. The distance from the jugular notch to the nipple was 25.5 cm on the right breast and 24.5 cm on the left breast. Postoperative bra size is 36C. The distance from the jugular notch to the nipple is 22 cm on each breast. |
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A 24-year-old patient, postoperative lateral view at dressing change. Preoperative bra size was 36DD. The distance from the jugular notch to the nipple was 25.5 cm on the right breast and 24.5 cm on the left breast. Postoperative bra size is 36C. The distance from the jugular notch to the nipple is 22 cm on each breast. Note the ecchymosis on the lateral part of the breast. |
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| Media file 17:
A 24-year-old patient, postoperative view at first dressing change. Preoperative bra size was 36DD. The distance from the jugular notch to the nipple was 25.5 cm on the right breast and 24.5 cm on the left breast. Postoperative bra size is 36C. The distance from the jugular notch to the nipple is 22 cm on each breast. |
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A 36-year-old patient, preoperative view. Bra size is 38D. The distance from the jugular notch to the nipple is 31.5 cm on each breast. |
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| Media file 19:
A 36-year-old patient, appearance 2 months after breast reduction by suction alone; 570 mL was removed from the right breast and 550 mL from the left breast. The distance from the jugular notch to the nipple is 28 cm on the right breast and 28 cm on the left breast. Preoperatively, bra size was 38D. The distance from the jugular notch to the nipple was 31.5 cm on each breast |
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| Media file 20:
A 36-year-old patient, preoperative lateral view. Bra size is 38D. The distance from the jugular notch to the nipple is 31.5 cm on each breast. |
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| Media file 21:
A 36-year-old patient, lateral view of the breast 2 months after breast reduction by suction alone; 570 mL was removed from the right breast and 550 mL from the left breast. The distance from the jugular notch to the nipple is 28 cm on the right breast and 28 cm on the left breast. Preoperatively, bra size was 38D. The distance from the jugular notch to the nipple was 31.5 cm on each breast |
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Breast Reduction, Liposuction Only excerpt Article Last Updated: Oct 5, 2006
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