Breast Reduction Short Scar Methods

Short Scar Peri-areolar Inferior Pedicle Reduction

The short scar peri-areolar inferior pedicle reduction (SPAIR) mammaplasty became popular with the aim of resolving some of the problems and frustrations with more traditional inferior-based pedicle and new vertical reduction techniques. The use of the more familiar inferior pedicle provides a pedicle with which most surgeons are already comfortable and provides greater control over the final breast shape.

The inferior pedicle is considered to be easier to inset than a superior pedicle and the final on-table breast shape is more predictable of the final breast shape, as opposed to the often exaggerated final breast shape than can be encountered with other vertical breast reduction techniques. There are also two critical steps that further contribute to the final breast shape which help distinguish the SPAIR technique from others. Firstly, internal sutures are sometimes placed, and secondly, Scarpa’s fascia’s attachment to the inferior mammary fold remains intact.

The SPAIR mammaplasty is best reserved for reductions up to 1 kg. Although its use is possible in larger reductions, shaping the skin envelope becomes more challenging in such patients.

Breast Reduction: Short Scar Peri-areolar Inferior Pedicle Reduction – Markings

The breast meridian is marked from the clavicle down through the breast and across the infra-mammary fold. The infra-mammary crease is traced. A pedicle base of 8 cm in length is marked along the infra-mammary crease and is centred on the breast meridian. The breast is gently elevated superiorly and a distance of 8-10 cm is measured from the medial and lateral edge of the base of the pedicle onto the breast. This determines the amount of skin that will remain after the extra breast tissue is removed. The superior aspects of these two lines are then connected with a soft concave mark. The superior portion of the nipple-areola complex is marked by transposing the infra-mammary crease onto the anterior surface of the breast.

The medial and lateral margins of the skin resection are made by gently lifting the breast up and out and up and in, respectively. During these manoeuvres, the breast meridian is connected to the meridian at the infra-mammary crease. Rotating the breast superiorly is designed to approximate the final breast size and shape. The superior, inferior, medial, and lateral edges are all connected, wit the final arrangement resembling an elongated oval. At the level of the nipple, the medial skin resection margin will be at least 12 cm away from the mid-line to avoid too much tension on the closure. The new areola is marked 50 mm in diameter. The final shape of the inferior pedicle is drawn to incorporate the new areola.

Breast Reduction: Short Scar Peri-areolar Inferior Pedicle Reduction – Technique

The inferior pedicle with a 0.5 cm margin around the new areola is deepithelialized. Medial and superior flaps are raised (note: these flaps begin below the dermis and become roughly 4-6 cm thick as the pectoralis fascia is approached. The lateral flap maintains a thickness of roughly 2 cm throughout its length). The inferior pedicle is then dissected and the attachments of Scarpa’s fascia
at the inferior aspect of the breast are not disturbed.

Once the extra breast tissue is removed, internal support sutures are sometimes required to help better shape the breast. Both the superior and medial breast flaps are undermined for almost 2-3 cm. The leading deep edge of the undermined superior flap is advanced superiorly for 4–6 cm under itself and fixed to the pectoralis fascia. This advancement improves upper pole fullness. Th e medial edge is sutured to itself with interrupted suture. These sutures are separated by 2-3 cm. The overall effect is one of rounding the breast contour medially.

If the inferior pedicle is exceptionally floppy or loose, interrupted placation sutures can be placed into the pedicle itself to provide temporary stability until scar develops. However, patients who have either no upper pole concavity, a thick texture to the subcutaneous fat, or a short breast, do not
require these internal fixation sutures.

Th e inferior skin envelope is designed by first placing the patient in a sitting position to allow gravity to pull down on the breast. The inferior pedicle is carefully drawn upward, which creates a fold in the inferior skin envelope both medially and laterally to the pedicle. The most dependent portion of each fold is pulled together and held in place with a temporary staple. Then, the medial and lateral flaps are pulled upward and are stapled together while imbricating (overlapping) the redundant tissue. The staples are adjusted as necessary to create a pleasing breast shape. The staples are removed and the redundant tissue is resected. The skin over the inferior pedicle portion of the lower skin envelope is deepithelialized. The medial and lower skin edges are sutured to each other.

The peri-areolar skin envelope is shaped by first placing a purse-string suture using CV-3 Gore-Tex to create a pocket that finally measures 4.5 cm in diameter. This newly defined border is approximately circular in shape. Small areas of skin at the border of this pocket might be de-epithelialized to create a more circular shape. The areola is inset and secured with absorbable suture.

Breast Reduction: Short Scar Peri-areolar Inferior Pedicle Reduction – Outcomes

Short scar techniques have gained in popularity because they have eliminated the horizontal scar, improved breast projection, and maintained the final breast shape for a greater period as compared to more traditional techniques. Outcomes for vertical reduction mammaplasty techniques have been excellent.

Despite initial concerns, large volume breast reductions (> 1 kg) have also been successfully performed, although some studies showing a slightly higher rate of complications. Massive volume reductions (> 2 kg) have also been successfully performed.

There are no reliable prospective, randomized trials evaluating and comparing various short scar techniques with other short-scar or more traditional approaches. However several large studies have
examined outcomes using various variations of the Lejour and Hall-Findlay techniques. These studies all reach similar conclusions with patient satisfaction and final breast form and function being excellent, whilst complications are generally low and acceptable.

In one large study, the complication rate was 5.6%, with 2.2% superficial wound dehiscence and 1.2% haematoma as the two most common complications. Whilst Lejour’s relatively recent review of personal cases reports a complication rate of around 12%, with 5% seroma and 5.4% delayed wound healing as the two most common complications. The rate of retained or improved nipple sensation was consistent with or slightly better (85%) than the rates seen with an inferior
pedicle technique.

Although poorly evaluated within the studies, the percentage of women who could breast feed following a vertical reduction appears to be not to differ from the percentage of women who could breast feed with an inferior pedicle pattern technique. In a small study, 8/10 women who wanted to breast feed following vertical reduction mammaplasty were able to do so completely. Rates of nipple loss were universally reported at less than 1%.

One of the most consistent criticisms of some of the short-scar techniques is the inability to visualize the final breast shape immediately postoperatively. A majority of the vertical techniques create an exaggerated breast contour, which ultimately requires some time for the breast to “settle” into its final shape. As a result, two complications may sometimes develop: Firstly there is the risk that the the nipple-areola complex can be positioned too high, and secondly, asymmetry between the breasts can be more frequently noted.

To avoid such above-mentioned outcomes, it is important to create adequate lower pole support by tightly securing the medial and lateral poles to help prevent significant “bottoming-out”. Some surgeons might also also mark the nipple roughly 1-1.5 cm lower than the typical preoperative mark so as to allow for it moving higher.

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