Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.     

Is breast feeding possible after reduction mammaplasty?

The purpose of this study was (1) to evaluate the frequency of breast feeding in patients who had given birth following reduction mammaplasty using an inferiorly based pedicle flap and (2) to identify operative and nonoperative factors that may affect breast feeding following reduction mammaplasty. Seventy-three patients between the ages of 18 and 40 years were contacted and sent a standardized questionnaire. Data collected included age at pregnancy, duration of breast feeding, difficulties while breast feeding, and reasons for discontinuing breast feeding. A total of 20 patients of the 68 who responded had become pregnant following reduction mammaplasty. All 20 women lactated. Seven of these women (35 percent) went on to a breast-feed successfully, whereas 13 (65 percent) decided not to breast-feed or discontinued breast feeding for a variety of personal reasons.     

Self-reported symptoms among women after cosmetic breast implant and breast reduction surgery

A retrospective cohort study was performed in Sweden to evaluate the possibility that an individual symptom or constellation of illness symptoms related to silicone occurs in women after breast implant surgery. A random sample (n = 2500) of all women in the Swedish national implant registry who underwent breast augmentation surgery with alloplastic breast implants during the years 1965 through 1993 was compared with a sample (n = 3500) of women who underwent breast reduction surgery during the same period, frequency matched to the implant patients for age and calendar year at the time of surgery. In total, 65 percent of the breast implant patients (n = 1546) and 72 percent of the breast reduction patients (n = 2496) completed a self-administered questionnaire covering 28 rheumatologic and other symptoms and lifestyle and demographic factors. Practically all of the 28 symptoms inquired about were reported more often by women in the breast implant cohort, with 16 (57 percent) significantly more common in breast implant recipients. In contrast, few significant differences or consistent patterns were observed in the length of time since the implant and in the type (silicone or saline) or volume of the implant. Although women with breast implants report a multitude of symptoms more often than women who have breast reduction surgery, the lack of specificity and absence of dose-response relationships suggest that the excess of reported symptoms is not causally related to cosmetic implants.     

Island rat groin flaps with twisted pedicles

Clinical attempts are made to avoid rotating a flap and twisting the pedicle for fear of perfusion compromise. Torsion of an island rat groin flap pedicle is not a well-recognized experimental entity. The authors describe the results of island flap rotation with pedicle twisting in the rat groin flap model. Forty male Wistar rats were randomly divided into four groups of 10 animals each. In each group, bilateral groin flaps were elevated; one flap was sutured in place without rotation and the contralateral flap was subjected to 180, 270, 360, or 720 degrees of rotation. Blood flow within the flaps was assessed by laser Doppler flowmetry, and flap edema and necrosis were determined 10 days postoperatively. No differences were noted between control flaps and those subjected to 180 and 270 degrees of rotation. Although flaps subjected to 360 degrees of rotation demonstrated a large amount of postoperative edema and congestion of the subcutaneous tissue with some histologic changes, all flaps in this group survived. Measured flap weights at death were different from those of controls. All flaps subjected to 720 degrees of rotation underwent ischemic necrosis. Because of the differences between human skin architecture and rat skin architecture it cannot be concluded that similar results would be observed in any human skin flap. There might be three important points arising from this study of unknowingly twisted island groin flap pedicles in the rat model: (1) twisting of less than 360 degrees has no effect on flap survival; (2) twisting of 720 degrees is always associated with skin flap necrosis; (3) twisting of 360 degrees, although associated with some changes, does not cause skin flap necrosis.     

Nipple or areolar reduction with simultaneous breast augmentation

Patients requesting nipple or areolar reduction often desire simultaneous breast augmentation. A technique is described for implant placement by means of a nipple base incision with either nipple reduction or intraareolar reduction. Nipple reduction is accomplished by removing a ring of skin from the base of the nipple, while areolar reduction is performed by removing a donut-shaped area of skin whose inner diameter is at the nipple base. The elasticity of the areolar skin allows for access for saline implant placement. The resulting scar is well concealed. Results from 15 patients demonstrate that the technique is safe, practical, and appears to pose no increased risk of sensory changes to the nipple.     

Precision in breast reduction

Precision in the design and performance of a breast reduction can be enhanced by careful formulation of the criteria. The breast cone should incline about 15 degrees medialward. The intersection of the midshoulder (anterior iliac) spine line with the inframammary fold offers a reference point for horizontal localization of the nipple. The nipple-suprasternal notch length, the diameter of the areola, and the nipple-inframammary fold length are determined by the height of the patient and the size of the brassiere cup. On this basis, a table for breast reduction can be drawn up that gives these dimensions for a given height and size of brassiere cup. Other important factors include the stretch direction of the skin and the course of the nerve to the nipple. A distinction is made between radial segment conization and anterior tangential conization. Criteria and measurements were incorporated into a technique comprising anterior tangential excision of glandular tissue and limited inferior radial segment excision of skin.     

Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer

As the inclusion criteria for breast conservation therapy have continued to evolve to include lower quadrant tumors, very large breasts, and central tumors, the potential for significant disfigurement after breast conservation therapy has also increased. This has led some centers to develop coordinated oncology-plastic surgery approaches to ensure both adequate cancer resection and aesthetic appearance to the breasts. The authors applied this principle to a specific group of breast cancer patients--women with macromastia--who would benefit from reduction mammaplasty. Eleven women were identified from the senior author's (S.L.S.) reconstructive practice who underwent breast conservation therapy followed by breast reconfiguration and bilateral reduction mammaplasty. Preoperative brassiere sizes ranged from 34D to 46D. All women had immediate reduction after frozen sections from the lumpectomy/partial mastectomy margins were determined to be negative. A total of 22 reduction mammaplasties were performed (eight free-nipple grafts, five inferior pedicle flaps, seven superomedial pedicle flaps, and two superolateral flaps) and an average of 1085 g was removed per breast. All patients underwent radiation therapy postoperatively. There were eight minor complications in six patients (one hematoma, one keloid, one radiation burn, two cases of nipple hypopigmentation, and three cases of fat necrosis). After an average of 24 months' follow-up, there were no local recurrences and one death from distant metastasis. Seven of the 11 patients were available and agreed to rate their aesthetic satisfaction on the basis of a scale from 1 to 4, with 4 being the best. The mean satisfaction score was 3.3. Aesthetic outcomes before radiation therapy and after radiation therapy were evaluated by a panel of plastic surgery residents blinded to the purpose of the study. Using a scale of 1 to 4, the aesthetic mean before radiation therapy was 2.9 and the aesthetic mean after radiation therapy was 3.03. By combining breast conservation therapy with breast reconfiguration or reduction in large-breasted women, multiple benefits are derived. Larger segmental or partial mastectomies can be performed without disfigurement risk, ensuring adequate surgical margins. Immediate reconfiguration of the breast with reduction of the contralateral side creates symmetric, aesthetically pleasing breasts; allows contralateral breast tissue to be evaluated; and spares women from undergoing a second operative procedure. Such a coordinated program gives women an important boost, both physically and psychologically, during management of their breast cancer.     

Reproductive performance of dairy cows with ovarian cysts after different GnRH and cloprostenol treatments

Cystic ovarian disease is an important cause of reproductive failure and economic loss for the dairy industry. This report describes two consecutive studies. The objective of the first was to evaluate the response of cows with ovarian cysts to two therapeutic treatments. In the second study, we compared the effectiveness of the best treatment established in Study 1 with that of the Ovsynch protocol. For Study 1, cows were considered to have an ovarian cyst if it was possible to observe a single follicular structure with a follicular antrum diameter > 25 min in the absence of a corpus luteum in three ultrasonographic examinations performed at 7 days intervals. At diagnosis (Day 0), cows were assigned to one of two treatment groups. Cows in Group GnRH/CLP (n = 31) were treated with 100 microg GnRH i.m. and 500 microg cloprostenol (CLP) i.m. on Day 14. Cows in Group GnRH-CLP/CLP(n = 32) were treated with 100 microg GnRH i.m. plus 500 microg CLP i.m. on Day 0, and 500 microg CLP i.m. on Day 14. The animals were inseminated at observed estrus and monitored weekly by ultrasonography for 4 weeks or until Al. Cows in the GnRH-CLP/CLP group showed a lower cystic persistence rate (15.6% < 45.2%; P = 0.01); a higher estrus detection rate (84.4% > 41.9%; P < 0.0001); a higher ovulation rate (75% versus 32.3%; P < 0.0001) and a higher early response rate (31% > 3%; P = 0.02) than those in the GnRH/CLP group. For the second study, 128 cows with ovarian cysts were randomly assigned to one of two treatment groups: cows in Group Ovsynch (n = 64) were treated with 100 microg GnRH i.m. on Day 0, 500 microg CLP on Day 7, and 100 microm GnRH i.m. 36 h later. Cows in this group were inseminated 24 h after the second GnRH dose (Ovsynch protocol). Cows in Group GnRH-CLP/CLP/GnRH (n = 64)were treated as those in the GnRH-CLP/CLP group of Study 1 but received GnRH 32 h after the second CLP treatment and were inseminated 24 h after this. A further group of cows without ovarian cysts inseminated at natural estrus served as the Group Control (n = 64). Cows in the GnRH-CLP/CLP/ GnRH group showed a lower cystic persistence rate (10.9% < 46.9%; P < 0.0001); higher ovulation rate (79.7% > 17.2%; P < 0.0001); higher return to estrus rate (34.3% > 12.5%; P < 0.01) and higher pregnancy rate (28.1% > 3.1%; P < 0.01) than those in Ovsynch; and a similar pregnancy rate (28.1% versus 35.9%) to Control cows. These findings indicate that lactating cows with ovarian cysts can be successfully synchronized and time inseminated using a protocol that combines GnRH and CLP, starting treatment by simultaneously administering both products. This protocol also allows the insemination of cows showing estrus within the first week of treatment. Ovarian cysts were less responsive when treatment was started with GnRH alone.     

Subglandular breast reduction: the evolution of a minimal scar approach to breast reduction

The authors describe a new modification of the breast reduction procedure. By means of an inframammary incision, the breast is mobilized from the chest wall, and a "doughnut" annulus of breast tissue is removed from the undersurface of the gland. No skin is excised. The nipple-areola complex is left attached to a central core of breast tissue that receives its blood supply from the subdermal plexus of vessels. When the resulting defect is closed within the breast by strategically placed sutures, the base of the gland is narrowed, the breast is projected forward, and the circumareolar and vertical scars of other techniques are eliminated. The authors report their results in a series of 37 patients.