Breast reduction
Reduction mammoplasty (also breast reduction and reduction mammaplasty) is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the patient's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the patient's self-image, and of the patient's mental health.[1]
Anatomy of the breast[edit]
The procedure[edit]
A reduction mammoplasty to re-size enlarged breasts and to correct breast ptosis resects (cuts and removes) excess tissues (glandular, adipose, skin), overstretched suspensory ligaments, and transposes the NAC higher upon the breast hemisphere. During puberty, the breast grows in consequence to the influences of the hormones estrogen and progesterone; as a mammary gland, the breast is composed of lobules of glandular tissue, each of which is drained by a lactiferous duct that empties to the nipple. Most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules, except during pregnancy and lactation, when breast milk constitutes most of the breast volume.[12]
Composition[edit]
Surgically, the breast is an apocrine gland overlaying the chest – attached at the nipple and suspended with ligaments from the chest – which is integral to the skin, the body integument of the individual. The dimensions and weight of the breasts vary with age and habitus (body build and physical constitution); hence, small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750–1,000 gm.[15][16][17] Anatomically, the breast topography and the hemispheric locale of the NAC are particular to each individual; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (NAC to IMF).
Blood supply and innervation[edit]
The arterial blood supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery (from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries. Drainage of venous blood from the breast is by the superficial vein system under the dermis, and by the deep vein system parallel to the artery system. The primary lymph drainage system is the retromammary lymph plexus in the pectoral fascia. Sensation in the breast is established by the peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerves, and thoracic spinal nerve 4 (T4 nerve) innervates and supplies sensation to the NAC.[18][19]
Surgical techniques[edit]
Pre-operative matters[edit]
The medical treatment records for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the oversized breasts, the sternal-notch–to-nipple distances, and the nipple-to–inframammary-fold distances. The patient is instructed about the purposes of the breast reduction surgery; the achievable corrections; the expected final size, shape, and contour of the reduced breasts; the expected final appearance of the breast reduction scars; possible changes in the sensation of the NAC; possible changes in breast-feeding capability; and possible medical complications. The patient also is instructed about post-operative matters, such as convalescence, and the proper care of the surgical wounds to the breasts.
Incision-plan delineation: to the breasts of the standing patient, the plastic surgeon delineates the mosque dome skin-incision plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (IMF), and the vertical axis of the breast, beneath the IMF. The upper edge of the (future) NAC is marked slightly below the IMF-level, and a semicircle of 16-cm maximum diameter. In relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. The circumference of the (future) NAC is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future NAC circumference; the incision-plan delineation continues down as a cone, and around the marked circumference.
Operative technique[edit]
The patient is laid supine upon the operating table so that the surgeon can later raise them to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. Afterwards, the pedicle epidermis surrounding the NAC is cut, and adipose tissue is liposuctioned from the breast. The medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. Then, the NAC is transposed higher upon the breast hemisphere. The pillars of parenchymal tissue are approximated (joined), and the skin envelope is sutured.[24][25][26] There is no evidence to support using drains during breast reduction surgery.[21]