Reduction mammoplasty (also breast reduction and reduction mammaplasty) is the
plastic surgery
Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...
procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional
bust
Bust commonly refers to:
* A woman's breasts
* Bust (sculpture), of head and shoulders
* An arrest
Bust may also refer to:
Places
* Bust, Bas-Rhin, a city in France
*Lashkargah, Afghanistan, known as Bust historically
Media
* ''Bust'' (magazin ...
that is proportionate to the woman's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and
lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process naturally occurs with all sexually mature female mammals, although it may predate mammals. The proces ...
al capability of the breasts. The indications for breast reduction surgery are three-fold – physical,
aesthetic
Aesthetics, or esthetics, is a branch of philosophy that deals with the nature of beauty and taste, as well as the philosophy of art (its own area of philosophy that comes out of aesthetics). It examines aesthetic values, often expressed th ...
, and psychological – the restoration of the bust, of the woman's
self-image
Self-image is the mental picture, generally of a kind that is quite resistant to change, that depicts not only details that are potentially available to an objective investigation by others (height, weight, hair color, etc.), but also items that h ...
, and of her
mental health
Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health ...
.
In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to
mastopexy
Mastopexy (Greek μαστός ''mastos'' "breast" + -pēxiā "affix") is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. ...
(breast lift).
Presentation
The woman with
macromastia
Breast hypertrophy is a rare medical condition of the breast connective tissues in which the breasts become excessively large. The condition is often divided based on the severity into two types, macromastia and gigantomastia. Hypertrophy of the ...
presents heavy, enlarged breasts that sag and cause her chronic pains to the head, neck, shoulders, and back; an oversized
bust
Bust commonly refers to:
* A woman's breasts
* Bust (sculpture), of head and shoulders
* An arrest
Bust may also refer to:
Places
* Bust, Bas-Rhin, a city in France
*Lashkargah, Afghanistan, known as Bust historically
Media
* ''Bust'' (magazin ...
also causes her secondary health problems, such as poor
blood circulation
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
, impaired
breathing
Breathing (or ventilation) is the process of moving air into and from the lungs to facilitate gas exchange with the internal environment, mostly to flush out carbon dioxide and bring in oxygen.
All aerobic creatures need oxygen for cellular ...
(inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassière-strap indentations to the shoulders; and the improper fit of clothes.
In the woman affected by
gigantomastia
Breast hypertrophy is a rare medical condition of the breast connective tissues in which the breasts become excessively large. The condition is often divided based on the severity into two types, macromastia and gigantomastia. Hypertrophy of the ...
(>1,000 gm overweight per breast), the average breast-volume reduction diminished her oversized bust by three brassière cup-sizes. The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations that a bodily disproportionate bust imposes upon a woman; thereby it improves her physical and
mental health
Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health ...
. Afterwards, the woman's ability to comfortably perform physical activities previously impeded by oversized breasts improves her emotional health (
self-esteem
Self-esteem is confidence in one's own worth or abilities. Self-esteem encompasses beliefs about oneself (for example, "I am loved", "I am worthy") as well as emotional states, such as triumph, despair, pride, and shame. Smith and Mackie (2007) d ...
) by reducing
anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
and lessening
psychological depression
Depression is a mental state of low mood and aversion to activity, which affects more than 280 million people of all ages (about 3.5% of the global population). Classified medically as a mental and behavioral disorder, the experience of ...
.
Medical history
The medical history records the woman's age, the number of children she has borne, her
breast-feeding
Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that brea ...
practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information, are her history of
tobacco smoking
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...
and concomitant diseases, breast-surgery and breast-disease histories, family history of
breast cancer
Breast cancer is cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a re ...
, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness.
The physical examination records and establishes the accurate measures of the woman's
body mass index
Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...
, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of
breast ptosis
The breast is one of two prominences located on the upper ventral region of a primate's torso. Both females and males develop breasts from the same embryological tissues.
In females, it serves as the mammary gland, which produces and secret ...
, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the nipple–areola complex (NAC), and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight,
kyphosis
Kyphosis is an abnormally excessive convex curvature of the spine as it occurs in the thoracic and sacral regions. Abnormal inward concave ''lordotic'' curving of the cervical and lumbar regions of the spine is called lordosis. It can result fr ...
(excessive, backwards curvature of the thoracic region of the
spinal column
The vertebral column, also known as the backbone or spine, is part of the axial skeleton. The vertebral column is the defining characteristic of a vertebrate in which the notochord (a flexible rod of uniform composition) found in all chordates ...
), skin irritation, and skin rash affecting the breast crease (IMF).
Cause
A woman develops large breasts usually during
thelarche
Thelarche, also known as breast budding, is the onset of secondary breast development, often representing the beginning of pubertal development. It is the stage at which male and female breasts differentiate due to variance in hormone levels; howe ...
(the pubertal breast-development stage), but large breasts can also develop postpartum, after gaining weight, at
menopause
Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often d ...
, and at any age. Whereas macromastia usually develops in consequence to the
hypertrophy
Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It is distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number.Updated by Linda J ...
(overdevelopment) of adipose fat, rather than to milk-gland hypertrophy. Moreover, many women are
genetically
Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinian friar working i ...
predisposed to developing large breasts, the size and weight of which often are increased either by
pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ca ...
or by weight gain, or by both conditions; there also exist
iatrogenic
Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 2 ...
(physician-caused) conditions such as post–
mastectomy
Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operat ...
and post–
lumpectomy
Lumpectomy (sometimes known as a tylectomy, partial mastectomy, breast segmental resection or breast wide local excision) is a surgical removal of a discrete portion or "lump" of breast tissue, usually in the treatment of a malignant tumor or brea ...
asymmetry. Nonetheless, it is statistically rare for a young woman to experience virginal mammary hypertrophy that results in massive, oversized breasts, and recurrent
breast hypertrophy
Breast hypertrophy is a rare medical condition of the breast connective tissues in which the breasts become excessively large. The condition is often divided based on the severity into two types, macromastia and gigantomastia. Hypertrophy of the ...
.
The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the overdevelopment of the milk glands or of the
adipose tissue
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular e ...
, or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild (<300 gm) to the moderate (ca. 300–800 gm) to the severe (>800 gm). Macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging,
breast ptosis
The breast is one of two prominences located on the upper ventral region of a primate's torso. Both females and males develop breasts from the same embryological tissues.
In females, it serves as the mammary gland, which produces and secret ...
that is determined by the degree to which the nipple has descended below the inframammary fold (IMF).
Therapeutic approaches
Medical
Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy; yet a weight-reduction regimen for the over-weight woman can alleviate some of the excessive size and volume of her abnormally enlarged breasts. Physical therapy provides some relief for neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chafing, infection, and bleeding.
Surgical
The traditional surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; yet it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar – around the NAC, where the dark-to-light skin-color transition hides the surgical scar.
Anatomy of the breast
The procedure
A reduction mammoplasty to re-size enlarged breasts and to correct
breast ptosis
The breast is one of two prominences located on the upper ventral region of a primate's torso. Both females and males develop breasts from the same embryological tissues.
In females, it serves as the mammary gland, which produces and secret ...
resects (cuts and removes) excess tissues (
glandular
In animals, a gland is a group of cells in an animal's body that synthesizes substances (such as hormones) for release into the bloodstream (endocrine gland) or into cavities inside the body or its outer surface (exocrine gland).
Structure
De ...
,
adipose
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular ...
,
skin
Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation.
Other cuticle, animal coverings, such as the arthropod exoskeleton, have diffe ...
), overstretched suspensory ligaments, and transposes the NAC higher upon the breast hemisphere. During
puberty
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a boy. ...
, the breast grows in consequence to the influences of the
hormone
A hormone (from the Greek participle , "setting in motion") is a class of signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and behavior. Hormones are required ...
s
estrogen
Estrogen or oestrogen is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens that have estrogenic hormonal acti ...
and
progesterone
Progesterone (P4) is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species. It belongs to a group of steroid hormones called the progestogens and is the m ...
; as a
mammary gland
A mammary gland is an exocrine gland in humans and other mammals that produces milk to feed young offspring. Mammals get their name from the Latin word ''mamma'', "breast". The mammary glands are arranged in organs such as the breasts in primat ...
the breast is composed of lobules of glandular tissue, each of which is drained by a
lactiferous duct
Lactiferous ducts are ducts that converge and form a branched system connecting the nipple to the lobules of the mammary gland. When lactogenesis occurs, under the influence of hormones, the milk is moved to the nipple by the action of smooth mus ...
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
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ca ...
and
lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process naturally occurs with all sexually mature female mammals, although it may predate mammals. The proces ...
, when
breast milk
Breast milk (sometimes spelled as breastmilk) or mother's milk is milk produced by mammary glands located in the breast of a human female. Breast milk is the primary source of nutrition for newborns, containing fat, protein, carbohydrates ( lacto ...
constitutes most of the breast volume.
Composition
Surgically, the breast is an
apocrine gland
Apocrine () glands are a type of exocrine gland, which are themselves a type of gland, i.e. a group of cells specialized for the release of secretions. Exocrine glands secrete by one of three means: holocrine, merocrine and apocrine. In apocrine ...
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 woman. The dimensions and weight of the breasts vary with her 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. Anatomically, the breast topography and the hemispheric locale of the NAC are particular to each woman; 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
The
arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the pulmonary vein, the left chambers of the heart, and in the artery, arteries. It is bright red in color, while venous blood is dark red in color (but looks purple through ...
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
Venous blood is deoxygenated blood which travels from the peripheral blood vessels, through the venous system into the right atrium of the heart. Deoxygenated blood is then pumped by the right ventricle to the lungs via the pulmonary artery whic ...
from the breast is by the superficial vein system under the
dermis
The dermis or corium is a layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided i ...
, and by the deep vein system parallel to the artery system. The primary
lymph
Lymph (from Latin, , meaning "water") is the fluid that flows through the lymphatic system, a system composed of lymph vessels (channels) and intervening lymph nodes whose function, like the venous system, is to return fluid from the tissues to ...
drainage system is the retromammary lymph plexus in the
pectoral fascia
The pectoral fascia is a thin lamina, covering the surface of the pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and bel ...
. 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
nerve
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
s, and
thoracic spinal nerve 4
The thoracic spinal nerve 4 (T4) is a spinal nerve of the thoracic segment.
Mechanical structures of the breast
In realizing the breast-reduction corrections, the plastic surgeon takes
anatomic
Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having its ...
and
histologic
Histology,
also known as microscopic anatomy or microanatomy, is the branch of biology which studies the microscopic anatomy of biological tissues. Histology is the microscopic counterpart to gross anatomy, which looks at larger structures vis ...
account of the biomechanical, load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (Poisson's ratio of ~0.5).
# Rib cage. The 2nd, 3rd, 4th, 5th, and 6th ribs of the thoracic cage are the structural supports for the mammary glands.
# Chest muscles. The breasts overlay the
pectoralis major muscle
The pectoralis major () is a thick, fan-shaped or triangular convergent muscle, situated at the chest of the human body. It makes up the bulk of the chest muscles and lies under the breast. Beneath the pectoralis major is the pectoralis minor, a ...
, the
pectoralis minor muscle
Pectoralis minor muscle () is a thin, triangular muscle, situated at the upper part of the chest, beneath the pectoralis major in the human body.
Structure
Attachments
Pectoralis minor muscle arises from the upper margins and outer surfaces ...
, and the intercostal muscles (between the ribs), and can extend to and cover a portion of the (front) anterior serratus muscle (attached to the ribs, the rib muscles, and the shoulder blade), and to the
rectus abdominis muscle
The rectus abdominis muscle, ( la, straight abdominal) also known as the "abdominal muscle" or simply the "abs", is a paired straight muscle. It is a paired muscle, separated by a midline band of connective tissue called the linea alba. It exte ...
(a long, flat muscle extending up the torso, from pubic bone to rib cage). The body posture of the woman exerts physical stresses upon the pectoralis major muscles and the pectoralis minor muscles, which cause the weight of the breasts to induce static and dynamic
shear force
In solid mechanics, shearing forces are unaligned forces acting on one part of a body in a specific direction, and another part of the body in the opposite direction. When the forces are collinear (aligned with each other), they are called t ...
s (when standing and when walking), compression forces (when lying supine), and tension forces (when kneeling on four limbs).
# Pectoralis fascia. The pectoralis major muscle is covered with a thin superficial membrane, the
pectoral fascia
The pectoral fascia is a thin lamina, covering the surface of the pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and bel ...
, which has many prolongations intercalated among its fasciculi (fascicles); at the midline, it is attached to the front of the
sternum
The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sh ...
, above it is attached to the
clavicle
The clavicle, or collarbone, is a slender, S-shaped long bone approximately 6 inches (15 cm) long that serves as a strut between the shoulder blade and the sternum (breastbone). There are two clavicles, one on the left and one on the rig ...
(collar bone), while laterally and below, it is continuous with the fascia.
# Suspensory ligaments. The subcutaneous layer of
adipose tissue
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular e ...
in the breast is traversed with thin suspensory ligaments (
Cooper's ligaments
Cooper's ligaments (also known as the suspensory ligaments of Cooper and the fibrocollagenous septa) are connective tissue in the breast that help maintain structural integrity. They are named for Astley Cooper, who first described them in 1840. ...
) that extend obliquely to the skin surface, and from the skin to the deep
pectoral fascia
The pectoral fascia is a thin lamina, covering the surface of the pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and bel ...
. The structural stability provided by the Cooper's ligaments derives from its closely packed bundles of
collagen
Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
fibers oriented in parallel; the principal, ligament-component cell is the
fibroblast
A fibroblast is a type of cell (biology), biological cell that synthesizes the extracellular matrix and collagen, produces the structural framework (Stroma (tissue), stroma) for animal Tissue (biology), tissues, and plays a critical role in wound ...
, interspersed throughout the parallel collagen-fiber bundles of the shoulder,
axilla
The axilla (also, armpit, underarm or oxter) is the area on the human body directly under the shoulder joint. It includes the axillary space, an anatomical space within the shoulder girdle between the arm and the thoracic cage, bounded superior ...
, and
thorax
The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the cre ...
ligaments.
# Glandular tissue. As a mammary gland, the breast comprises lobules (milk glands at each lobe-tip) and the
lactiferous duct
Lactiferous ducts are ducts that converge and form a branched system connecting the nipple to the lobules of the mammary gland. When lactogenesis occurs, under the influence of hormones, the milk is moved to the nipple by the action of smooth mus ...
s (milk passages), which widen to form an ampulla (sac) at the nipple.
# Adipose tissue. The fat tissue of the breast is composed of lipidic fluid (60–85% weight) that is 90–99 per cent
triglycerides
A triglyceride (TG, triacylglycerol, TAG, or triacylglyceride) is an ester derived from glycerol and three fatty acids (from ''tri-'' and ''glyceride'').
Triglycerides are the main constituents of body fat in humans and other vertebrates, as we ...
, free
fatty acids
In chemistry, particularly in biochemistry, a fatty acid is a carboxylic acid with an aliphatic chain, which is either saturated or unsaturated. Most naturally occurring fatty acids have an unbranched chain of an even number of carbon atoms, f ...
,
diglycerides
A diglyceride, or diacylglycerol (DAG), is a glyceride consisting of two fatty acid chains covalently bonded to a glycerol molecule through ester linkages. Two possible forms exist, 1,2-diacylglycerols and 1,3-diacylglycerols. DAGs can act as s ...
, cholesterol
phospholipids
Phospholipids, are a class of lipids whose molecule has a hydrophilic "head" containing a phosphate group and two hydrophobic "tails" derived from fatty acids, joined by an alcohol residue (usually a glycerol molecule). Marine phospholipids typ ...
, and minute quantities of
cholesterol
Cholesterol is any of a class of certain organic molecules called lipids. It is a sterol (or modified steroid), a type of lipid. Cholesterol is biosynthesized by all animal cells and is an essential structural component of animal cell mem ...
ester
In chemistry, an ester is a compound derived from an oxoacid (organic or inorganic) in which at least one hydroxyl group () is replaced by an alkoxy group (), as in the substitution reaction of a carboxylic acid and an alcohol. Glycerides ar ...
s, and
monoglycerides
Monoglycerides (also: acylglycerols or monoacylglycerols) are a class of glycerides which are composed of a molecule of glycerol linked to a fatty acid via an ester bond. As glycerol contains both primary and secondary alcohol groups two differen ...
; the other components are water (5–30% weight) and protein (2–3% weight).
# Fatty tissue. In biology, adipose tissue (/ˈædəˌpoʊs/), or body fat or fat depot or just fat, is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts. Its main role is to store energy in the form of lipids, although it also cushions and insulates the body. Far from hormonally inert, adipose tissue has in recent years been recognized as a major endocrine organ as it produces hormones such as leptin, resistin, and the cytokine TNFα. Moreover, adipose tissue can affect other organ systems of the body and may lead to disease. Obesity or being overweight in humans and most animals does not depend on body weight but on the amount of body fat – to be specific, adipose tissue. Two types of adipose tissue exist: white adipose tissue (WAT) and brown adipose tissue (BAT). The formation of adipose tissue appears to be controlled in part by the adipose gene. Adipose tissue was first identified by the Swiss naturalist Conrad Gessner in 1551.
# The skin envelope. The breast skin is in three layers: (i) the
epidermis
The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and hypodermis. The epidermis layer provides a barrier to infection from environmental pathogens and regulates the amount of water rele ...
, (ii) the
dermis
The dermis or corium is a layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided i ...
, and (iii) the
hypodermis
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and macro ...
. The epidermis is 50–100 μm thick, and is composed of a
stratum corneum
The stratum corneum (Latin for 'horny layer') is the outermost layer of the epidermis. The human stratum corneum comprises several levels of flattened corneocytes that are divided into two layers: the ''stratum disjunctum'' and ''stratum compact ...
of flat
keratin
Keratin () is one of a family of structural fibrous proteins also known as ''scleroproteins''. Alpha-keratin (α-keratin) is a type of keratin found in vertebrates. It is the key structural material making up scales, hair, nails, feathers, ho ...
cells, that is 10–20 μm thick; it protects the underlying viable epidermis, which is composed of keratinizing
epithelial cells
Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellula ...
. The dermis is mostly
collagen
Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
and
elastin
Elastin is a protein that in humans is encoded by the ''ELN'' gene. Elastin is a key component of the extracellular matrix in gnathostomes (jawed vertebrates). It is highly elastic and present in connective tissue allowing many tissues in the bod ...
fibers embedded to a viscous water and
glycoprotein
Glycoproteins are proteins which contain oligosaccharide chains covalently attached to amino acid side-chains. The carbohydrate is attached to the protein in a cotranslational or posttranslational modification. This process is known as glycos ...
medium. The fibers of the upper dermis ("papillary dermis") are thinner than the fibers of the deep dermis, thus the skin envelope is 1–3 mm thick. The thickness of the hypodermis (adipocyte cells) varies from woman to woman, and body part. The skin of the nipple and areola is further composed of a modified and specialized myoepthelium that is responsible for contraction in response to stimuli.
Surgical procedures
General
Reduction mammoplasty, either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a woman affected either with macromastia (>500 gm increase per breast) or with gigantomastia (>1,000 gm increase per breast). Breast reduction surgery has two technical aspects: (i) the skin-incision pattern and the skin- and glandular-tissue excision technique applied for access to and removal of breast
parenchyma
Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms.
Etymology
The term ''parenchyma'' is New Latin from the word π ...
tissue. The incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars; (ii) the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of
nerves
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
and blood vessels (
arterial
An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pul ...
and
venous
Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
) that ensure its tissue viability.
The specific reduction mammoplasty procedure is determined by the volume of breast tissues (
glandular
In animals, a gland is a group of cells in an animal's body that synthesizes substances (such as hormones) for release into the bloodstream (endocrine gland) or into cavities inside the body or its outer surface (exocrine gland).
Structure
De ...
,
adipose
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular ...
,
skin
Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation.
Other cuticle, animal coverings, such as the arthropod exoskeleton, have diffe ...
) to be resected (cut and removed) from each breast, and the degree of breast ptosis present: Pseudoptosis (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold); Grade I: Mild ptosis (the nipple is below the IMF, but above the lower pole of the breast); Grade II: Moderate ptosis (the nipple is below the IMF; yet some lower-pole breast tissue hangs lower than the nipple); Grade III: Severe ptosis (the nipple is far below the IMF; no breast tissue is below the nipple). The full, corrective outcome of the surgical re-establishment of a bodily proportionate bust becomes evident at 6-months to 1-year post-operative, during which period the reduced and lifted breast tissues settle upon and into the chest. The post-operative convalescence is weeks long, depending upon the corrections performed; and some women might experience painful breast-enlargement during the first post-operative
menstruation
Menstruation (also known as a period, among other colloquial terms) is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is characterized by the rise and fall of hor ...
.
Contraindications
Breast reduction surgery cannot be performed if the woman is lactating, or has recently ceased lactating; if her breasts contain unevaluated tissue masses, or unidentified microcalcifications; if she has a
systemic illness
A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole.
Examples
* Mastocytosis, including mast cell activation syndrome and eosinophilic esophagitis
* Chronic fatigue syndrome
* Systemic va ...
; if she is unable to understand the technical limitations of the plastic surgery; and her inability to accept the possible medical complications of the procedure. Additionally, recent research has indicated that mammograms should not be done with any increased frequency in patients undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction.
I. Inferior pedicle technique (anchor pattern, inverted-T incision, Wise pattern)
The inferior pedicle (central mound) features a blood vessel supply (arterial and venous) for the NAC from an inferior, centrally-based attachment to the chest wall. The skin pedicle maintains the
innervation
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
and
vascular
The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...
viability of the NAC, which produces a reduced, sensitive breast with full
lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process naturally occurs with all sexually mature female mammals, although it may predate mammals. The proces ...
al capability and function. The volume and size reduction of hypertrophied breasts is performed with a periareolar incision to the NAC, which then extends downwards, following the natural curve of the breast hemisphere. After cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the NAC is transposed higher upon the breast hemisphere; thereby the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the woman's person. Nonetheless, breast-reduction with an inferior pedicle, occasionally produces breasts that appear squared; yet, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia.
II. Vertical scar technique (lollipop incision)
The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision
scar
A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a na ...
s and a NAC elevated by means of a pedicle (superior, medial, lateral) that maintains the biologic and
functional
Functional may refer to:
* Movements in architecture:
** Functionalism (architecture)
** Form follows function
* Functional group, combination of atoms within molecules
* Medical conditions without currently visible organic basis:
** Functional sy ...
viability of the NAC. The increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the NAC . The vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars.
III. Horizontal scar technique
The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a NAC pedicle. To elevate the NAC, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the anchor pattern). The horizontal-scar technique best applies to the woman whose oversized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed NAC. The potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold.
IV. Free nipple-graft technique
The breast reduction performed with the free nipple-graft technique transposes the NAC as a tissue
graft
Graft or grafting may refer to:
*Graft (politics), a form of political corruption
* Graft, Netherlands, a village in the municipality of Graft-De Rijp
Science and technology
*Graft (surgery), a surgical procedure
*Grafting, the joining of plant t ...
without a blood supply, without a skin and glandular pedicle. The therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. The therapeutic disadvantage is a breast without a sensitive NAC, and without
lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process naturally occurs with all sexually mature female mammals, although it may predate mammals. The proces ...
al capability. The medically indicated candidates are: the woman whose health presents a high risk of
ischemia
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems wi ...
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...
tissue necrosis
Necrosis () is a form of cell injury which results in the premature death of Cell (biology), cells in living Tissue (biology), tissue by Autolysis (biology), autolysis. Necrosis is caused by factors external to the cell or tissue, such as infec ...
; the
diabetic
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased app ...
woman; the woman who is a
tobacco smoker
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...
; the woman whose oversized breasts have an approximate NAC-to-IMF measure of 20 cm; and the woman who has macromastia, requiring much resecting of the breast tissues.
V. Liposuction-only technique (lipectomy)
The breast reduction performed with the liposuction-only technique usually applies to the woman whose oversized breasts require the removal of a medium volume of internal tissue; and to the woman whose health precludes her being under the extended
anaesthesia
Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), a ...
usual to surgical breast-reduction operations. The ideal lipectomy candidate is the woman whose low-density breasts are principally composed of
adipose tissue
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular e ...
, have a relatively elastic skin envelope, and manifest mild ptosis. The therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior, hence, a shorter post-operative healing period for the incision scars; the therapeutic disadvantage is limited breast-reduction volumes.
Surgical techniques
Pre-operative matters
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 woman 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
scar
A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a na ...
s; possible changes in the sensation of the NAC, possible changes in her
breast-feeding
Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that brea ...
capability, and possible medical complications. The woman 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
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.
There is no evidence to support using drains during breast reduction surgery.
Notes
* Biological: The resected tissue is submitted to
histopathologic
Histopathology (compound of three Greek words: ''histos'' "tissue", πάθος ''pathos'' "suffering", and -λογία ''-logia'' "study of") refers to the microscopic examination of tissue in order to study the manifestations of disease. Spec ...
examination, because sub-clinical
breast cancer
Breast cancer is cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a re ...
foci occur in 0.1–0.9 per cent of the tissue specimens.
* Technical: The original Lejour technique incision plan had no horizontal limbs, and so did not produce horizontal scars; however, contemporary variants, such as the Modified Lejour Technique, employ small, horizontal incisions along the inframammary fold, in order to avoid redundant skin folds, especially in the reduction of very oversized breasts.
Post-operative matters
The woman is instructed to resume her normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassière; the convalescence regimen is for 3-months post-operative. She is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within 1–6 months post-operative; yet some cases might require surgical revision of the vertical scar. Scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications.
There is limited evidence in showing wound drains have no significant benefit after reduction mammoplasty.
Complications
The post-operative complications occurred included
seroma
A seroma is a pocket of clear serous fluid (filtered blood plasma). They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, ...
,
wound dehiscence
Wound dehiscence is a surgical complication in which a wound ruptures along a surgical incision. Risk factors include age, collagen disorder such as Ehlers–Danlos syndrome, diabetes, obesity, poor knotting or grabbing of stitches, and trauma ...
,
hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...
; whereas partial NAC
necrosis
Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
occurred in 10 per cent of the reduced breasts; yet, after refinement of the Lejour technique, the study ''Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases'' (1999), reported a reduced incidence rate of 7.0 per cent in the 324 breast reductions performed in 167 patients. Moreover, the incidence of such post-operative complications is greater among the women whose breasts required large-volume resection of the
parenchyma
Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms.
Etymology
The term ''parenchyma'' is New Latin from the word π ...
; in women who were
obese
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
; in women who were
tobacco smokers
Tobacco smoking is the practice of burning tobacco and ingesting the resulting tobacco smoke, smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with tobacco pipes, pipes and cig ...
; and in young women. Furthermore, wound dehiscence, epidermolysis,
adipose tissue
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular e ...
necrosis, and
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
occur less among women who undergo Lejour-technique breast reduction, than among women who undergo a periareolar, anchor pattern breast-reduction, or an inferior-pedicle breast reduction. Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 per cent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 per cent of the women; and total NAC insensitivity occurs in 1.0 per cent of women.
Liposuction-only technique
The reliability of the lipectomy procedure was confirmed in two studies. The first, '' Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction'' (2000) reported that tumescent
liposuction
Liposuction, or simply lipo, is a type of fat-removal procedure used in plastic surgery. Evidence does not support an effect on weight beyond a couple of months and does not appear to affect obesity-related problems. In the United States, lipo ...
is a reliable reduction mammoplasty procedure, which yields consistent results of size, appearance, and texture of the reduced-volume breasts. The second study by Daniel Lanzer, ''Breast Reduction with Liposuction'' (2002), about a 250-woman cohort, reported that the application of tumescent liposuction, as the sole reduction-mammoplasty procedure, yielded consistent results wherein none of the patients had loose breast-skin envelopes, irregular breast-shape, permanent loss of sensation (either glandular, dermal, or of the NAC), scars, tissue
necrosis
Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
, or infection.
After fat cells are suctioned away via
liposuction
Liposuction, or simply lipo, is a type of fat-removal procedure used in plastic surgery. Evidence does not support an effect on weight beyond a couple of months and does not appear to affect obesity-related problems. In the United States, lipo ...
body fat
Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular en ...
generally returned to the same level as before treatment. This is despite maintaining the previous diet and exercise regimen. While the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. Visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack.
Indications
The reduction of oversized breasts by liposuction only (lipectomy) is indicated when a minor-to-moderate volume-reduction is required, and there is no
breast ptosis
The breast is one of two prominences located on the upper ventral region of a primate's torso. Both females and males develop breasts from the same embryological tissues.
In females, it serves as the mammary gland, which produces and secret ...
to correct. However, in a 2001 study of 250 patients, nipple and breast elevation of between 3 cm and 15 cm was reported. Further indications for lipectomy are presented by: (i) the woman who requires a large-volume reduction, and wants un-scarred, sensate breasts, yet will accept a degree of ptosis; (ii) the woman who requires a secondary mammoplasty to correct an asymmetric breast, by up to one brassière cup-size; and (iii) the girl affected by
virginal breast hypertrophy
Breast hypertrophy is a rare medical condition of the breast connective tissues in which the breasts become excessively large. The condition is often divided based on the severity into two types, macromastia and gigantomastia. Hypertrophy of the ...
, as a temporary procedure performed before the conclusion of her
thelarche
Thelarche, also known as breast budding, is the onset of secondary breast development, often representing the beginning of pubertal development. It is the stage at which male and female breasts differentiate due to variance in hormone levels; howe ...
(the pubertal breast-growth phase), given the hypertrophy's high rate of recurrence.
Contraindications
Breast reduction by liposuction only cannot be performed upon a woman whose
mammogram
Mammography (also called mastography) is the process of using low-energy X-rays (usually around 30 kVp) to examine the human breast for diagnosis and screening. The goal of mammography is the early detection of breast cancer, typically through d ...
indicates that the oversized breast is principally composed of hypertrophied milk glands. Furthermore, liposuction mammoplasty also is contraindicated for any woman whose mammograms indicate the presence of unevaluated
neoplasm
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope.
Pre-operative matters
Consultation: the plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The woman is informed of the alternative,
surgical
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
reduction techniques available for diminishing her oversized breasts; of the consequent surgical
scar
A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a na ...
s; of the possible loss of breast sensation; of the possible impairment of
lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process naturally occurs with all sexually mature female mammals, although it may predate mammals. The proces ...
capability; and of the possible impairment of
breast-feeding
Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that brea ...
functions. The woman is further informed of the possible medical complications, and is shown surgical photographic records of the average outcomes of breast-reduction surgery. The surgeon answers the woman's questions to assist her in establishing realistic expectations (
self-image
Self-image is the mental picture, generally of a kind that is quite resistant to change, that depicts not only details that are potentially available to an objective investigation by others (height, weight, hair color, etc.), but also items that h ...
) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the volume of her breasts, a secondary, surgical breast-reduction procedure can be performed later.
The measures of the bust: a liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the woman's breasts, chest, and torso. Yet the measures of the bust are established in order to determine the required degree(s) of correction; thus, with the patient sitting erect, for each breast, the surgeon records the jugular-notch-to-nipple distances, the nipple-to-inframammary-fold distances, and any asymmetries. Afterwards, the anaesthetized patient is laid supine upon the operating table, with her arms laterally extended (abducted) in order to fully expose the breasts.
Anaesthestic preparation: to limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast's circulatory system is established with an
anaesthetic
An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia — in other words, to result in a temporary loss of sensation or awareness. They may be divided into two ...
solution (
lidocaine
Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...
+
epinephrine
Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
in
saline solution
Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein it ...
) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforation
cannula
A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
, the anaesthetic infiltration begins at the deep plane of the breast, and continues as the cannula is withdrawn towards the superficial plane of the breast. The entire area of the breast is infiltrated with the anaesthetic solution until the tissues become tumescent (firm). Moreover, as required by the patient's physique, an intravenous (IV) pressure bag can be applied to hasten the infiltration; after the anaesthetic has numbed the breast, the plastic surgeon begins the lipectomy breast-reduction.
Operative technique
The surgeon effects a stab incision just above the lateral aspect of the inframammary fold (IMF), piercing the skin 2-cm above the inframammary fold, in the midline. The pre-tunnelling is performed with the blunt-tip, multi-perforation cannula used to infiltrate the
anaesthetic
An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia — in other words, to result in a temporary loss of sensation or awareness. They may be divided into two ...
solution to the breast tissues. A blunt-tip, 4-mm cannula, connected either to a medical-grade vacuum pump or to a syringe, is used to aspirate the adipose fat. The cannula is maneuvered laterally (in fanning movements), beginning in the deep plane of the breast and concluding in the superficial plane of the breast; the adipose fat sucked from the breast is a yellow, fatty, bloodless fluid; the liposuction concludes upon drawing the required volume of fat, or when the fat becomes bloody.
After the liposuction, the superficial layer of adipose fat is undermined with a blunt-tip, 3-mm cannula (which is not connected to a vacuum pump). The breast ptosis is corrected by stimulating the controlled retraction of the incision scar, by undermining the superficial fat of the medial and the lateral upper areas of the breast; the maneuver tightens (retracts) the skin envelope of the breast. Procedurally, the liposuction-only breast reduction procedure concludes with the application of an elastic, foam-tape dressing that molds the reduced breast into its new shape, and lifts it higher upon the chest.
Technical note: for the reduction of very enlarged breasts, the plastic surgeon makes a supplementary incision just above the medial aspect of the inframammary fold. Procedurally, the placement of this incision later allows converting the lipectomy breast-reduction procedure into an inferior-pedicle breast reduction surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts.
Post-operative matters
Convalescence
The patient is discharged from hospital either the same day or the day after the breast reduction operation. Because the liposuction-only procedure featured only a few, small, surgical incisions, the woman quickly recovers her health, usually resuming daily life activities at 14 to 28 days post-operative – when the breast-molding dressings are changed; she also resumes her personal hygiene regimen to include washing under a water shower. In the initial convalescence period, the surgical-incision wounds are inspected at 1-week post-operative, during which time the woman has continuously worn a strapless brassière to contain and immobilize her corrected breasts; afterwards, she continuously wears a strapped brassière for 30 days after the breast-reduction operation.
Complications
Early complications include
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
and
hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...
(blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require either
surgical
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
or
liposuction
Liposuction, or simply lipo, is a type of fat-removal procedure used in plastic surgery. Evidence does not support an effect on weight beyond a couple of months and does not appear to affect obesity-related problems. In the United States, lipo ...
revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although the
edema
Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...
usually subsides at 2–3 weeks post-operative. To date, no incidence of tissue
necrosis
Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
has been reported; likewise, there have been few reports of lessened nipple sensation. Generally, the long-term rate of patient-satisfaction is high, provided that the indications for the liposuction-only technique are abided with proper patient selection.