Breast Reduction

Description of the Problem

Surgical planning depends on the type of breast hypertrophy (overgrowth)

Type 1:

The increase in volume is predominantly in the central and upper chest. Gravity draws the tissue downwards and the distance from nipple to collarbone increases greatly while that to the crease under the breast only increases slightly.

Type 2:

The gland has overdeveloped in the lower part of the breast. More skin stretch occurs below the nipple so the distance from the nipple to the fold increases.

Type 3:

A combination of the above, where both measurements increase significantly.

Fig. 1: type I	Fig. 2: type II	Fig. 3: Type III

Figures 1,2,3: The three different types of breast hypertrophy

 

Aims of Surgery

The problem results from an excess of both skin and tissue. Surgery therefore reduces the volume and in addition re-drapes the skin to produce a pleasing shape. In doing so, the nipple is repositioned and the areola reduced in size where necessary.

 

Technical Aspects of the Surgery

There have been considerable advances in the surgical techniques for breast reduction over the last 50 years. Initially, volume reduction was the principal aim. This was refined to also provide a pleasing shape. More recent advances enable us to achieve the above while minimizing the extent of the scarring. Focus is also maintained on maintaining the blood flow and sensation to the nipple and areola complex.

Before the operation the surgeon draws a number of complex planning marks on the patient’s chest. It is important to carry this out while the patient is upright as the relationships change when lying down for surgery. The measurements calculate the amount of tissue to be removed and the new nipple height. It is difficult to plan for a specific desired breast shape, but following consultation an approximate breast size can be agreed. Usually, a C cup is seen as the best balance between breast and chest size, but this can be modified to suit the patient’s preference.

The procedure has three principal components. A tissue ‘pedicle’ is designed to retain blood flow and feeling to the nipple. Excess skin and tissue are then removed, before the breast is finally brought into a pleasing shape and closed. A number of alternatives exist for each of these stages.

The blood supply to the nipple can be achieved through ‘pedicles’ arising from different directions and they can be designed in different thicknesses.
Likewise, breast tissue can be removed mainly from the top, bottom, or outside of the breast. After a wedge of tissue is removed, bringing the remaining tissue together produces a pleasant breast ‘cone’.

The excess skin can be removed in any of the ways described for a breast lift. There will be a scar around the areola and one extending vertically downwards. In some techniques called ‘vertical scar’ these are the only scars. Commonly though, an additional scar across the fold under the breast is needed to achieve the ideal shape. Overall, there are two techniques that are most commonly employed.

 

The vertical scar technique (of Lassus and Lejour)

Here the nipple and areola are left with a blood supply from above. A wedge of tissue is removed from the lower part of the breast and the only scarring is around the areola and vertically down to the fold under the breast. The main advantage is minimal scarring. The disadvantages are that blood flow to the nipple may be reduced as might sensation. Skin is only pulled in horizontally in the lower part of the breast so excess skin along the vertical line might allow sag of the overlying tissue to re-occur. The patients for this procedure have to be carefully selected.

 

Fig. 4 a	Fig. 4 b	Fig. 4 c
Fig. 4 d	Fig. 4 e	Fig. 4 f
Fig. 4 g	Fig. 4 h

Figure 4: The vertical scar technique: (a) preoperative markings (b) the nipple is cut around and the skin underneath undermined; a pedicle of skin and a thin layer of intact gland are preserved (c, d) a wedge of tissue underneath the nipple is then removed; (e, f) the nipple is moved upwards by folding this tissue on itself; (g) The remaining tissue is brought together; (h) the skin is stitched with the wound deliberately ‘crumpled’ to shorten the final scar.

 

Perforator based technique (of Blondeel)

 

 Here the nipple and areola remain supported by ‘perforating’ vessels which come through the pectoralis major muscle from below. This technique also takes into consideration the sensory nerves to the nipple which can be preserved in most cases. Tissue is mainly removed from underneath and above the nipple. To optimally reduce the skin in the lower half, a scar of variable length in the crease underneath the breast is necessary. The main advantages of this modification lie in the robust blood and nerve supplies to the nipple and a natural shape to the breast and areola following surgery.

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Fig. 5 a	Fig. 5 b	Fig. 5 c
Fig. 5 d	Fig. 5 e	Fig. 5 f
Fig. 5 g	Fig. 5 h

Figure 5: (a) Preoperative markings. (b) Skin is undermined and removed with preservation of the blood supply to the nipple (c) the lower, horizontal part of the gland is removed (d) vertical part is removed taking away breast gland below, medial and above the nipple-areola complex (e, f) the column of tissue with the nipple still attached is tilted upwards (g) the remaining tissue is brought together (h) the skin is closed with an ‘anchor’ shaped or inverted-T scar.

What to expect after surgery

There will be a dressing along the wounds on each breast. Some elastic tape or a special bra may be used to support the breast. There will often be tubes coming out through the adjacent skin to drain off any excess fluid that accumulates following surgery. These can be removed between 24 and 48 hours afterwards.
It is normal to see the following after surgery:

• Bruising, mostly around the areola, but the colour can spread across the chest. Swelling of the breast also commonly occurs. This gets worse over the first few days then gradually improves.
• Temporary loss of sensation of the nipple, areola or surrounding skin. This is common and can take weeks to months to fully recover, depending on the procedure. There will also be some pain after the operation. The initial ache fades, but as the scars mature there will be occasional stinging pain over the following months.

Examples

Figure 6: Pre(above) and postoperative (below) pictures of a prominent Type III breast hypertrophy who underwent a breast reduction using the Blondeel technique. 

Figure 7: Pre(above) and 11 years postoperative (below) pictures of a Type I breast hypertrophy who underwent a breast reduction using the Blondeel technique.

Length of Stay

The operation takes between 1.5 and 2.5 hours and the length of hospital stay is between 24 and 48 hours. The amount of fluid coming out through the drains usually determines this length of stay. Once it has slowed to an acceptable amount, they can be removed and the patient can go home.

Aftercare

If the wounds have been covered with protective glue, the top dressings can be removed to shower the following day. In other cases the wounds may need to be kept dry for a longer period.

Elastic tape can be replaced by a supportive (sports) bra when leaving the hospital. Surgeons vary in their preferences regarding the support of the breast and each will advise you accordingly. Usually, you will be asked to wear a bra day and night for up to 4 weeks. Normal bras can be worn again after 3 months.

For the first 48 hours, physical activity, particularly arm movements should be limited to a minimum, but after this, full mobility is encouraged. However, no heavy work or sports should be done for 3 weeks postoperatively. It is also not recommended to sleep on your stomach during the first 4 weeks. Depending on your type of work, 2-3 weeks should be taken off to fully recover.

Potential Complications

Early

Local

• Bleeding
• Infection
• Wound healing problems
• Skin irritation
• Nipple/areola necrosis
• Wound breakdown
• General
• ·Deep vein thrombosis
• ·Lung embolism
• ·Chest infection

Late

• Nipple or skin numbness
• Painful twinges
• Other sensory disturbances
• Scar hypertrophy (thickening)
• Asymmetry
• Dissatisfaction with the final volume
• Subsequent changes in shape with gravity and ageing

Financial Considerations

Although breast hypertrophy is not a disease per se it frequently causes unpleasant symptoms and disability to the sufferer. As such, some health care systems including those in Belgium, Holland and the United Kingdom will fund the procedure after considering each case on its individual merits. In some instances, however, all or part of the cost will need to be met by the patient. Policies vary between insurance companies and you should check first with your provider. Be sure to have everything clearly documented in writing by both your surgeon and insurer.

One Patient’s Experience

I decided to have a breast reduction not only because of the pain in my shoulders and the inflammation underneath my breasts, but also to improve their appearance. My breasts grew rapidly from a young age and I had finished with an F cup and inverted nipples.

I had kept my breasts hidden since my adolescence. No one else knew how frustrated, embarrassed and unconfident I felt about my breasts. They seemed to define who I was, how I functioned emotionally, socially and in relationships. Thanks to the internet, I found a solution.
My first meeting with a plastic surgeon was the hardest. I was so nervous that I struggled to hold back tears. Eventually, I regained control and was able to have an informed discussion about the operation.

At first I did not want anyone to know what I was doing, but then it became practically necessary and everyone was very understanding.
I decided with my surgeon to aim for a C cup. Before the surgery careful markings were made on my breasts. I was nervous about the anaesthetic, but soon drifted off and awoke to the first glimpse of my breasts.

At first I was scared, they looked shapeless and bruised. The pain was quite tolerable which was a big relief ! It was literally a weight off my shoulders.

In my post-operative visits, my surgeon reassured me that everything had gone well. Over the next 6 months my breasts took shape and I am very proud of them. My scars are healing nicely. The only remaining problem was my inverted nipples. The surgeon suggested that nipple piercings would help this and that it was a minor procedure under local anaesthetic.

I cannot and will not hide the fact that I have had plastic surgery. My breasts have been corrected and I am so happy with the result. I feel more confident. If I had known earlier what I know now, I would have acted more quickly. I have never once regretted having surgery.

 

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