Breast reduction
Breast reduction techniques
Breast reduction methods
Breast reduction short scar methods
Vertical Mammaplasty
Several short-scar reduction mammaplasty techniques have been introduced and applied in recent years, however the vertical mammaplasty is the most widely used.
Vertical mammaplasty was described as early as 1925. Th e Lejour vertical reduction, fi rst presented in 1989, is currently the most popular technique. Several adaptations of this technique have been proposed, however it remains popular due to its shorter scar and more stable and pleasing results when compared with other reduction mammaplasty approaches. It is the Lejour vertical reduction mammaplasty technique of breast reduction that is described here.
Breast Reduction: Vertical Mammaplasty – Markings
With the patient in standing position, the midline of the chest is marked from the suprasternal notch to the abdomen. The infra-mammary crease is traced from the midline to the anterior axillary line. The meridian begins from a point 8 cm from the sternal notch – over the clavicle – and extends toward the nipple. The vertical axis of the breast is then marked on the upper abdomen at the level of the infra-mammary crease. This line usually measures 8–14 cm from the midline but will vary the width of the chest.
The initial mark for the nipple-areola position varies depending upon personal preference. Typically the infra-mammary crease is projected onto the anterior breast, with the intersection of this line and the meridian delineating the new nipple position. Some surgeons have used either set measurements (19–22 cm) from the sternal notch to the meridian or have used the midpoint of the humerus to help define the nipple–areola position. The final position on either side can be adjusted to achieve breast symmetry.
The lateral resection margin is identified by gently rotating the breast medially and slightly superiorly. Whilst maintaining this breast position, the vertical axis is extended from the upper abdomen onto the breast. After displacing the breast gently laterally, the vertical axis is again extended onto the breast to define the medial skin resection margin. The farther the breasts are displaced, the greater the volume of the resection will be due to the increased distance between the lateral and medial borders.
A soft concave curve is used to join the medial and lateral marks inferiorly. This curve represents the inferior most aspect of skin resection and should be at least 2–4 cm superior to the infra-mammary crease. It is important to maintain an inferior margin above the starting of infra-mammary fold to prevent the vertical scar from extending distal to the final infra-mammary
crease. In general, the larger the final desired breast volume, the higher this mark will be placed.
The superior edge of the areola will reach about 2 cm above the new nipple. An elliptical or dome is drawn around the superior half of the new nipple position to outline the areola. The inferior edges of this mark connects with the medial and lateral breast markings. When the inferior edges of this semi-circle are pinched together to create a circle centred on the nipple, the total diameter will measure approximately 14–15 cm. Th e new areola size, 38–42 cm in diameter, is marked while the nipple–areola complex is unstretched. A line roughly 3–4 cm below the inferior aspect of this newly measured areola is created to mark the superior margin of tissue resection.
Breast Reduction: Vertical Mammaplasty – Technique
Under general anaesthesia, the patient is positioned supine on the operating room table with the arms abducted and secured. The patient will be placed in a sitting position prior to the final surgical preparation to confirm symmetric, desired positioning. Because it is difficult to determine pre-operatively if a breast has glandular and fatty tissue that can be suctioned adequately, suction-assisted lipectomy is tried at the very beginning.
Lidocaine (0.5%) with 1:100,000 epinephrine will be introduced in the area of resection, sparing the nipple areola region. The base of the breast will also be constricted. The area around the areola within the marking will be deepithelialized to a point roughly 3–4 cm below the inferior most aspect of the areola. Th e medial, lateral, and inferior markings are then incised.
An inferior skin flap, roughly 1.5 cm in thickness, is raised extending down to the infra-mammary crease. Th e breast is then shifted laterally so that the medial breast markings are in line with the vertical axis of the breast as marked at the infra-mammary fold. The dissection is carried straight down to the pectoralis fascia. For the lateral breast dissection, the technique is repeated once the breast is shifted medially, so that the lateral breast marking is in line with the vertical axis. The central breast tissue between the medial and lateral pillars is elevated from the pectoralis fascia beginning at its inferior edge. This dissection is carried out up to the level of the new nipple. Finally, the superior margin of resection is defined: an incision is made along the lower border of the deepithelialized tissue and extended down to the pectoralis fascia obliquely to create a superiorly based flap involving the new nipple-areola complex.
A heavy stitch is used to anchor the breast pedicle from its deep surface at the level of the new areola to the underlying fascia at the upper level of the retro-mammary dissection. The nipple–areola is next inset into its desired position. A drain may be placed not only to aspirate post-operative fluid and blood but also to help decrease dead-space. Medial and lateral pillars are
approximated with sutures placed on the anterior surface of the gland to promote breast projection. The dermis is approximated with a few interrupted sutures. The final sub-cuticular 3-0 Monocryl suture begins inferiorly and is used to gather the skin as it extends superiorly.
Using this technique a decrease of about a third of the wound length can be anticipated. The patient is placed in a surgical bra for 2–3 weeks. The drain is removed early post-operatively, usually within 24 hours.
