Disclosure Bilateral reduction mammaplasty reduces the size of hypertrophied or hyperplastic breasts. To create symmetry with a smaller or reconstructed contralateral breast, the procedure is unilateral. The vertical, bipedicle, reduction mammaplasty tailors the operation to accommodate a range of breast sizes. History of the Procedure: The bipedicle (vertical dermal flap) breast reduction, or McKissock reduction mammaplasty, has long been a standard to which other operative methods of breast reduction have been compared. McKissock, a California plastic surgeon, published his procedure in the March 1972 issue of Plastic and Reconstructive Surgery. He initially developed the procedure as a modification of the Strombeck procedure and refined it during the decade preceding publication, making it a safe and reproducible operation and an aesthetically pleasing one. Problem: Women with large breasts develop back and neck aches, progressive notching of the shoulders from the pressure of bra straps, and intermittent intertrigo. Frequent headaches may occur. Physical activity is cumbersome and positioning for sleep difficult. Presently, only operative treatment will correct female breast hypertrophy. Breast reduction surgery alleviates the symptoms produced by mammary hypertrophy. The vertical bipedicle reduction mammaplasty can be adapted to the entire range of size and volume encountered in breast hypertrophy. Frequency: In 1998, the American Society of Plastic Surgeons reported 70,358 reduction mammaplasties were performed in the United States. No comment was made on the type of reduction mammaplasty performed. A 1995 Canadian study by Carr and Freiberg sited a significant minority of Canadian plastic surgeons prefer the McKissock vertical bipedicle reduction mammaplasty across a wide range of clinical situations. Accurate statistics for the incidence of mammary hypertrophy are not available. Etiology: Classic research performed in the first 3 decades of the last century firmly established that ovarian steroids and pituitary peptide hormones are mandatory for sufficient breast development and lactation. The Mammary Genome Anatomy Project (MGAP) was established to identify and understand genetic pathways that are operative during normal mammary gland development and neoplasia. Normal breast ductal tissue sequences and gene sets have been identified. The inheritance of mammary gland hypertrophy is an area of intense investigation. Clinical: Bilateral breast hypertrophy presents at puberty or soon thereafter. Teenage females with large breasts frequently report that they are the subjects of ridicule. Some women develop breast hypertrophy during pregnancy that persists. In extremely rare instances, rapidly progressive unremitting breast enlargement known as virginal breast hypertrophy may occur. The symptoms of female breast hypertrophy relate to muscular discomfort, such as backache, neck ache, shoulder discomfort, and even headache. Patients complain of poor posture and ulnar nerve paresthesia. Hygienic problems in the submammary crease lead to irritations, rashes, and infection. Shoulder grooves develop over time from the pressure exerted by bra straps, but if a bra is not worn, activities and even sleep may be difficult. Women with large breasts frequently complain they cannot participate in sports and clothing is difficult to fit. Physical examination: Physical examination confirms the diagnosis of breast hypertrophy and rules out a diagnosis of breast carcinoma. The distance from the sternal notch to the nipple is often greater than 22 centimeters and the span from the inframammary crease to the nipple greater than 7 centimeters. Body surface area and excess breast tissue weight estimates correlate the expectation between symptoms and breast size. Secondary skeletal effects include postural changes with a tendency to dorsal kyphosis. Bra strap grooves deepen with time. Ulnar nerve compression may occur. Intermittent intertrigo may be a problem. Preoperative photographs document mammary hypertrophy. Consultations: The treating plastic surgeon may seek the help of a general surgeon for evaluation of breast nodularity or an abnormal mammogram. Suggested skeletal or neural disease processes require orthopedic, neurosurgical, or neurological consultations.
Relevant Anatomy: The female breast is a glandular structure that has a large variation in volume and shape. It occupies the area overlying the second to sixth ribs extending from the sternum to the anterior axillary line. The center of each nipple-areolar complex lies approximately 22 cm from the sternal notch and from its mate in women with small breasts. In women with mammary hypertrophy or hyperplasia, that distance is longer and often reaches more than 40 cm. The arterial supply of the breasts is from the lateral branches of the intercostal arteries, the lateral thoracic artery, and the perforating branches of the internal mammary artery. The nipple receives most of its blood supply from musculocutaneous perforating vessels from the pectoralis major muscle. These vessels travel through the breast tissue and supply the nipple-areolar complex. An additional and substantial dermal plexus of arteries also supplies the nipple-areolar complex and forms the basis of the vertical bipedicle technique. The anterior cutaneous branches of the first to seventh intercostal nerves innervate the skin of the medial breast and the lateral cutaneous branches of the second to seventh intercostal nerves the lateral breast. The anterior and lateral cutaneous branches of the fourth intercostal nerve innervate the nipple-areolar complex. Additional innervation to this complex is by the cutaneous branches of the third and fifth intercostal nerves. Contraindications:
Cessation of smoking and medications that adversely affect wound healing is important preoperatively. Before surgery, treatment of psychological instability is material. |
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Lab Studies:
Medical therapy: No medical treatment corrects female mammary hypertrophy. A special supportive brassiere may offer some relief but often increases the pressure on the shoulders. Surgical therapy: Bilateral reduction mammaplasty is the treatment of choice to alleviate the symptoms from mammary hypertrophy. A unilateral procedure achieves symmetry for a patient with a contralateral reconstructed breast after mastectomy for breast cancer. The choice of reduction mammaplasty technique varies, but the expected outcomes are similar. The vertical bipedicle reduction mammaplasty is a reliable, reproducible, and aesthetically pleasing procedure. Preoperative details: In addition to a history and physical examination, the initial consultation involves a discussion of the risks and benefits of the vertical bipedicle reduction mammaplasty procedure. The procedure abates back and neck aches, lessens the indentation of the shoulders from bra straps, and eliminates submammary intermittent intertrigo. Self-esteem is improved, and exercise is easier. Risks of the procedure includes infection, hematoma formation and bleeding, delayed wound healing with possible dehiscence of the incisions, and impaired vascularity of tissues with resultant loss of skin or nipple-areolar complex. Fatty necrosis of the breast tissue may result in a lumpiness of the breast tissue. Noticeable scarring is common, but hypertrophic scarring or keloid formation is rare. Aesthetic imperfections may require revisions. Nipple sensation may be impaired, and lactation generally is not possible. Preauthorization from the insurer is usually required (Chao, 2002; Scott, 2005). This may involve submission of photographs to the medical director. To rule out unsuspected pathology, a preoperative mammogram is ordered as needed, if not performed within the last year. Preparations are made for patients with larger breasts to donate autologous blood. Intraoperative details: Before coming to the operating room in the sitting position, the appropriate surgical markings are drawn with a marking pen. The sternal notch is marked. From this point, the midclavicular point is marked, and a line is drawn from this point to the nipple on each side. A midline vertical line is made from the sternal notch as a reference point. The submammary crease is transposed to the anterior breast on the previously drawn line from the midclavicular point to the nipple. This is the site of the advancement of the nipple and is approximately 22 cm from the sternal notch. In tall or mature women, this measurement is longer. It is better to err on low rather than high nipple placement, since it is difficult to correct a high nipple. A circumference is drawn around this point with a 38-cm diameter template. The vertical extent of the medial and lateral flaps is 5 cm and is drawn inferiorly from the planned areolar margin. The markings then progress in the horizontal direction medially and laterally to the extent of the breast. A horizontal line joins the lines in or slightly above the submammary crease. Careful planning is important for correct nipple placement and bilateral symmetry. Once the markings are in place, the patient is brought to the operating room. Prophylactic antibiotics may be given. The patient is anesthetized, and the relevant surgical markings are scratched in place with a sterile needle. Prepping and draping proceeds. A line is drawn from the nipple downward to approximately 11 cm from the medial extent of the horizontal incision. Further lines are dropped from the vertical flaps to the horizontal incision. This marks the width of the pedicle. The nipple is circumscribed with a 38-cm template, and then the skin superior and inferior is de-epithelialized. This marks the extent of the superior and inferior pedicles. The lateral and medial aspect of the pedicle is incised with a cautery unit. The lateral segment of tissue to be removed is incised through the skin, subcutaneous tissue, and breast tissue to the lateral chest wall. In a similar manner, the medial segment is removed. Finally, the breast tissue from the 12 o'clock position of the keyhole to the nipple is excised. All of the excised breast tissue is weighed. The wound is irrigated with saline and homeostasis maintained. A 5-0 Monocryl suture is used to approximate the 12 o'clock position of the nipple to the 12 o'clock position of the keyhole. The medial and lateral flaps are approximated to each other and then to the submammary crease incision. Interrupted 3-0 Monocryl sutures followed by a running subcuticular 3-0 Monocryl suture completes closure. Only one external pivot suture of 2-0 proline is used at the junction between the vertical and horizontal incisions. The nipple-areolar complex is closed with interrupted 5-0 Monocryl suture followed by a running subcuticular 4-0 Monocryl suture. The contralateral breast is addressed in a similar manner. At the end of the procedure, symmetry and good capillary refill of the areolar-nipple complexes are achieved. Maintaining the patient's normal temperature and adequate fluids and using care in handling the pedicle during the procedure prevents undue risk to the viability of the nipple. Once the procedure is complete, Steri-strips and light dressings are applied. A surgical bra may be worn. Postoperative details: Postoperative care includes adequate analgesics and uncomplicated wound management. The procedure may be performed in an outpatient or short stay setting. No lifting for a few weeks and frequent rest periods lead to an uncomplicated postoperative course. Women with small children will need help with their care. Follow-up care: Follow-up care is essential in the immediate postoperative phase and then within 24 hours to observe the patient's general condition and surgical site and to provide instructions to the patient and her personal caregiver. A follow-up office visit in a few days and a week or two later is important to monitor the patient and the surgical incisions. Some delayed healing at the "T" incision is common. External sutures, if present, are removed. If complications occur, additional visits are indicated. Once the incisions appear to be healing well and the patient is fine, long-term visits are planned for approximately 6 weeks, 3 months, 6 months, and 1 year. During this period, postoperative photographs are taken and outcomes recorded. Outcomes include documentation of the aesthetic result, long-term effects of gravity, scar maturation, nipple sensation, relief of preoperative symptoms, and patient satisfaction. Mammography, to establish a baseline for future breast cancer screening, can be repeated several months after surgery.
The reduction mammaplasty should match with the patient's expectations in alleviating symptoms and improving physical symptoms, the human relations issue, and cosmetic appearance. An outcome study from the Mayo Clinic in Scottsdale, Arizona was published in 1997. Of the respondents in the study, 94.2% believed the procedure was successful. Patients saw an improvement in body image, the ability to find clothes that fit, and the capacity to participate in sports. There was a decrease in notching of the shoulders from bra straps, and a decrease was observed in shoulder pain, upper back pain, neck pain, and intertrigo. Pain or numbness in the hands, headaches, arm pain, and breast pain decreased. Symptoms were either relieved or partially relieved in 88%, and 97.3% responded that they definitely or probably would undergo the procedure again. This outcome study supported the hypothesis that reduction mammaplasty is an effective procedure and the treatment of choice for symptomatic mammary hyperplasia. Postoperative documentation of objective improvement is in photographs and measurements of the nipple to sternal notch and the nipple to inframammary crease. This author has found a marked improvement in scarring in the vertical bipedicle reduction mammaplasty with the use of dissolvable, monofilament, buried sutures. A British study assessed aesthetic outcome of reduction mammaplasty. Most patients rated the aesthetic outcomes of their surgery significantly higher than the consultants did. Scarring was the most frequent cause of dissatisfaction for both surgeons and patients. Silicone gel sheeting in the postoperative period may help mitigate these scars. Symptomatic relief and improved body image independent of preoperative body weight was noted in a Philadelphia study. There were few significant differences between obese and nonobese women concerning the resolution of physical symptoms or improvement in body image. Slezak and Dellon found that postoperative sensory outcome depends on a combination of factors, but most patients with gigantomastia have improved nipple sensation after a McKissock breast reduction.
Several variations in surgical technique may offer an opportunity to reduce the extent of scarring in the small-to-moderate volume breast. No current medical treatment for female breast hypertrophy exists.
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