Breast sensitivity after vertical mammaplasty

Breast sensation after reduction mammaplasty is a major concern for surgeons and patients. The sensitivity of 80 breasts that were reduced using Lejour's technique (a superior dermoglandular pedicle with resection at the lower quadrants) was assessed in a prospective study. Ten points were selected on each breast for this study, including the nipple, four points on the areola, and five points on the breast skin. The measurements were performed preoperatively and at 3, 6, and 12 months postoperatively. Pressure thresholds were measured with 20 Semmes-Weinstein monofilaments, temperature sensitivity with hot and cold metal probes, vibratory thresholds with the Biotesiometer, and static and moving two-point discrimination tests with a Disk-Criminator. To assess the influence of breast ptosis and hypertrophy on sensitivity, the population was divided into two groups. In group I (19 patients), the sternal notch-to-nipple distance was less than 29 cm, and less than 500 g of tissue per breast was removed. In group II (21 patients), the sternal notch-to-nipple distance was more than 29 cm, and more than 500 g of tissue was resected. The sensitivity on the nipple and areola was significantly decreased at 3 and 6 months postoperatively for all modalities. At 1 year, sensitivity recovered, and no breast or nipple-areola complex was insensitive. Pressure sensitivity was not significantly different from the preoperative measurement in any area of the breast or in either group of patients, except for superior breast skin, for which sensitivity was improved in group II (p = 0.0004). Temperature sensitivity in group I was not different preoperatively and postoperatively, but in group II, a significant decrease was observed in sensitivity for the nipple and areola (p = 0.01 and 0.004, respectively). Vibratory sensitivity was significantly decreased on the nipple, the areola, and the inferior breast skin (p = 0.01, 0.01, and 0.001, respectively) in group II but not in group I.In conclusion, ptotic or moderately hypertrophied breasts that were reduced using Lejour's technique recovered their preoperative level of sensitivity after an initial postoperative decline. However, in large breasts, although pressure sensitivity recovered after 1 year, temperature and vibration sensitivity remained diminished on the nipple-areola complex.     

Reduction mammaplasty improves breast sensibility

The belief that breast hypesthesia is an expected consequence of reduction mammaplasty is based on past reports that failed to objectively quantify breast sensibility. Forty-five women undergoing reduction mammaplasty by one plastic surgeon using a single operative technique were followed prospectively for change in breast sensation. Pressure threshold measurements were taken preoperatively and at 2 and 6 weeks postoperatively, by using Semmes-Weinstein monofilaments. Areas tested included the nipple, four points on the areola, and four points 1 cm from the areola on the breast skin. The data were nonparametric and were analyzed by using the Wilcoxon signed rank test. For all areas tested, sensation significantly improved from preoperatively to 2 weeks (i.e., nipple: 33.1 versus 29.3, p<0.0004) and again from 2 to 6 weeks (i.e., nipple: 29.3 versus 19.3, p<0.002). Relief of chronic nerve traction injury is conjectured as the reason for sensibility improvement. Numb nipples persisted in 2 percent of breasts at 6 weeks.     

Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques

The preservation of the sensitivity of the nipple-areola complex after reduction mammaplasty is an important goal. The authors performed this prospective study to accurately assess whether sensitivity changes are influenced by the weight of resection or the surgical technique. Eighty patients who underwent bilateral breast reduction (Lassus, 10 patients; Lejour, 13 patients; McKissock, 18 patients; Wuringer, 20 patients; and Georgiade, 19 patients) were tested for sensitivity changes of the nipple and cardinal points of the areola with Semmes-Weinstein monofilaments before surgery, at 3 weeks, and at 3, 6, and 12 months after surgery. Patient characteristics (age, body mass index, and preoperative sensitivity) were statistically similar in all groups. The mean resection weight was significantly smaller in the Lassus (540 g) and the Lejour groups (390 g) than in the Georgiade group (935 g). The sensitivity of the nipple and the inferior and lateral part of the areola was significantly lower after a superior pedicle technique (Lassus and Lejour) than after any other technique at 3 weeks and at 3, 6, and 12 months postoperatively. Insensate nipples and areolas were found only after breast reductions with the Lassus and the Lejour techniques (47.8 percent). Nipple sensitivity after breast reduction by the other techniques was unchanged (Wuringer, McKissock, and Georgiade) or sometimes even improved (Georgiade) as early as 3 weeks postoperatively. Changes in nipple and areola sensitivity after reduction mammaplasty depend on the surgical technique rather than the weight of resection. Superior glandular pedicle techniques that require tissue resections at the base of the breast are associated with a higher risk of injury to the nerve branches innervating the nipple-areola complex.     

Investigation into the possible cause of subjective decreased sensory perception in the nipple-areola complex of women with macromastia

Patients with macromastia often comment on a lack of sensation in their nipple-areola complex. A study was designed to investigate the cause of this decreased sensation. Two hypotheses were proposed. First, the decreased sensation could result from neuropraxia of the sensory nerve fibers secondary to traction caused by the heavy breast parenchyma. The second hypothesis proposed that tissue expansion of the nipple and areola by the voluminous breast parenchyma caused a decrease in nerve fibers per surface area and hence decreased sensory perception. Sixty-one patients were assessed in the study. All patients underwent surgery in which histological biopsy of either the areola alone (31 reduction mammaplasty patients) or the nipple and areola (30 mastectomy patients) was possible. Before surgery, each nipple-areola complex was tested with Weinstein Enhanced Sensory Test monofilaments as a quantitative test of tactile sensation. Breast cup size, ptosis, and weight of tissue excised were recorded to allow general assessment of the breast size. The nipple and areola biopsy specimens were assessed using immunohistochemistry (S-100 polyclonal antibody, Dako Z311) to measure nerve fiber count per unit area. Statistical analysis was undertaken to find any association among sensitivity, breast cup size, ptosis, weight of tissue resected, and nerve fiber density in the nipple and areola biopsy specimens. Sensitivity at the areola decreased with increasing breast cup size (r = 0.47, p < 0.001) and ptosis (r = 0.42, p = 0.002 for increasing distance between inframammary crease and nipple; r = 0.49, p < 0.001 for increasing manubrium to nipple distance). There was a weak correlation between nerve fiber density at the areola and breast cup size (r = -0.22, p = 0.1). Sensitivity at the nipple was higher than at the areola. Nerve fiber density count at the nipple was higher than at the areola, but there was no statistically significant correlation between nipple sensitivity and breast cup size, ptosis, or weight of tissue resected. The results suggest that the areola and nipple are different in their neuroanatomy. The areola is a thin, pliable structure that is predisposed to stretch as the breast enlarges and therefore experience a decrease in nerve fiber density. The nipple is a compact structure that is less likely to stretch with breast enlargement. In the nipple, neither sensory perception nor nerve fiber density varied with size or breast ptosis. The perceived lack of sensation in the nipple-areola complex is multifactorial. This study shows that neither traction injury to the sensory nerves nor decreased nerve density alone can explain the subjective numbness reported by patients with macromastia. Psychological factors, such as dissatisfaction with body form or interpretation of lack of sensation in the areola as also affecting the nipple, may influence the patient's assessment of the nipple-areola sensitivity.     

Quantitation of breast sensibility following reduction mammaplasty: a comparison of inferior and medial pedicle techniques

The preservation of sensitivity within the nipple-areola complex is of paramount importance to patients presenting for reconstructive and aesthetic breast procedures. Previous attempts to measure sensation in the breast before and after surgery have relied primarily on the Semmes-Weinstein monofilament test, which is an imprecise study that measures the logarithm of force necessary to bend a series of six to 20 filaments. Within the last 10 years, various authors have published normative pressure threshold data for the breast that have varied by a magnitude of greater than 10-fold. Recently, precise anatomic studies have been performed that have elucidated the innervation of the nipple-areola complex medially and laterally from cutaneous branches of the intercostal nerves. Despite this knowledge, no quantitative sensibility studies have yet been performed that compare postoperative sensation when medially versus laterally innervated pedicles have been used in reduction mammaplasty. The present study is the first to use computer-assisted neurosensory testing to generate normal breast sensation data and to compare sensory outcomes between the inferior and the medial pedicle techniques of reduction mammaplasty.A total of 34 patients were divided into four groups and underwent breast sensory testing (67 breasts total) using the Pressure-Specified Sensory Device, a computer-assisted force transducer that measures static and moving one and two-point discrimination. Sensation in the nipple and in the four quadrants of the areola was measured. Groups I and II were composed of 17 unoperated controls with breast sizes ranging from 34A to 36C (group I; 18 breasts) and 36DD to 46EE (group II; 16 breasts) who presented to a general plastic surgery clinic. Groups III and IV were composed of 17 patients who underwent either medial or inferior pedicle reduction mammaplasty between July of 1997 and March of 1999. Pressure thresholds in the most sensitive breasts were as low as 0.3 g/mm2, a marked contrast to data from previous studies using Semmes-Weinstein monofilaments documenting the lowest recordable pressure threshold as greater than 2 g/mm2. Several findings from previous studies using Semmes-Weinstein monofilament testing were confirmed in unoperated controls, including an inverse relationship between sensitivity and breast size, superior nipple sensitivity when compared with the areola, and significant interpatient variability with respect to static and moving two-point discrimination among women matched according to age and breast size. When comparing medial with inferior pedicle reduction mammaplasty patients, it was found that despite significantly greater reductions using the medial pedicle technique (mean of 1.7 kg versus 1.1 kg of breast tissue removed), there were no significant differences in postoperative sensory outcomes in the sample size of 17 patients. Furthermore, within each group of patients undergoing either the medial or inferior pedicle technique, the amount of breast tissue removed did not correlate with postoperative sensory outcomes.Computer-assisted quantitative neurosensory testing is a highly accurate technique for measuring sensibility. The use of this technology demonstrates a 10-fold difference in measurable sensory thresholds in normal patients from preexisting data using Semmes-Weinstein monofilaments. Advances in measurement methods have allowed the authors to compare postoperative sensory outcomes reliably using two popular techniques of reduction mammaplasty.     

Evaluation of breast sensibility using dermatomal somatosensory evoked potentials

This study was undertaken to prospectively evaluate breast sensibility before and after reduction mammaplasty with a new, objective, and quantitative neurophysiologic method based on the anatomic knowledge of breast innervation and the congruent areas of dermatomal maps. An innovative application of dermatomal somatosensory evoked potentials was used to study the breast regions of 42 healthy women, bilaterally. The areas stimulated in each breast were the superior quadrant, the nipple-areola complex and the medial and lateral quadrants, and the inferior quadrant; these areas correspond to T3, T4, and T5 dermatomes, respectively, following the accepted concepts of segmentary innervation of the skin. The two groups of 21 patients each were formed according to breast size: group I comprised small-breasted, unoperated controls (brassiere cup size A or B); group II comprised macromastia patients (brassiere cup size C or greater) who presented to a general plastic surgery department for breast reduction surgery. First the authors established the normal range of latency and amplitude in the dermatomal somatosensory evoked potentials for the five areas stimulated in patients with small breasts and compared these parameters with those obtained from patients with macromastia. Then, after the macromastia patients underwent reduction mammaplasty using the McKissock technique, the authors compared the postoperative sensory values with their own preoperative values and with those from the small-breasted group. Using dermatomal somatosensory evoked potentials, they found that small breasts were statistically more sensitive than large breasts, which concurs with studies in the literature that use other methods to evaluate breast sensibility. They also found that after breast reduction, the macromastia patients presented statistically significant improvement in breast sensibility in relation to their own preoperative latency and amplitude values, with no statistical difference in amplitude with respect to the small-breasted group; this finding suggests that after breast reduction, sensibility similar to that of the small-breasted group can be considered a possibility. Furthermore, in comparisons of each of the five areas stimulated, there was no significant difference in values within the small-breasted group or within the macromastia group before or after surgery; this supports a possible overlap between adjacent dermatomes. This innovative application of dermatomal somatosensory evoked potentials is an objective, quantitative, and noninvasive method that has allowed the authors to evaluate breast sensibility and to compare postsurgical sensory outcomes.     

Reduction mammaplasty provides long-term improvement in health status and quality of life

The objective of this study was to assess health status and quality of life in macromastia patients undergoing reduction mammaplasty. From January of 1997 to June of 1997, the Department of Reconstructive Plastic Surgery, at Stockholm S?der Hospital/Karolinska Hospital, conducted a prospective questionnaire study with preoperative and postoperative (6 and 12 months) assessments in 49 women who were 20 years or older. The questionnaire included four parts: Part I assessed pain (scale 1 to 10) in the neck, shoulders, back, breast, bra strap indention, and head. Part II assessed effects of breast size and weight on body posture, sleep, choice of clothing, sexual relations, and working capacity (scale 1 to 10). Part III assessed preoperative expectations for the operation in comparison with postoperative result (scale 1 to 6). Part TV included SF-36, an international health-related quality-of-life questionnaire, which has been standardized for Swedish women. As a result, reduction mammaplasty (mean resection weight, 1052 g) provided significant reduction of pain in all locations (p < 0.001). The improvements continued up to 12 months postoperatively. The patients' main subjective problems related to the size and weight of the breast were body posture and choice of clothing. The patients scored significant improvements of all subjective problems (p < 0.001), except sleep. The patients' expectations were met to a high extent. In some areas such as intimate situations, femininity, and social contacts, the results exceeded the preoperative expectations. Preoperatively, the mammaplasty patients scored significantly lower (p < 0.05 to p < 0.001, depending on area) in SF-36, i.e., the patients had lower quality of life compared with women in the same age group. Reduction mammaplasty resulted in significantly improved quality of life; furthermore, the results were similar after 6 and 12 months, indicating long-term improvement. In fact, after 1 year, there was no statistically significant difference between the patients who had been operated on and the age-matched women, i.e., the women were normalized in health-related quality of life as judged by the SF-36.     

Assessment of long-term nipple projection: a comparison of three techniques

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.     

Preservation of projection after reduction mammaplasty: long-term follow-up of the inferior pedicle technique

In reduction mammaplasty by the inferior pedicle technique, the dermal-breast pedicle can be manipulated to form a central breast mound and enhance breast projection. When this technique is applied both to macromastia and breast asymmetry, excellent early results are reported. To study the effects of time on breast reduction, 22 patients were followed for an average of 4.7 years. Contour of the breast mound and projection are well preserved. However, evaluation of long-term results reveals a gradual increase in the inframammary fold to inferior areola distance. Since no increase in the midclavicle to nipple distance is observed, inferior migration of the breast parenchyma and superior displacement of the nipple-areola with respect to the breast mound occur after reduction mammaplasty with the inferior pedicle technique.     

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.     

Three-year follow-up on clinical symptoms and health-related quality of life after reduction mammaplasty

The present study evaluated changes in patient health status and health-related quality of life 3 years after reduction mammaplasty. A previous investigation in the same study population of 49 women showed significant reduction of pain and subjective problems and improvement in health-related quality of life 6 and 12 months after the operation. The present article presents results on the health status and quality of life preoperatively and at 1 and 3 years after reduction mammaplasty. The same questionnaires were used regarding pain scored in six different locations (on a 10-point grading scale), subjective problems related to the size and weight of the breast (on a six-point grading scale), expectations of the operation (on a six-point grading scale), and health-related quality of life (with the Medical Outcomes Study 36-Item Short-Form Health Survey, or Short Form-36). The 39 women who answered the questionnaire (response rate, 80 percent) scored minor nonsignificant changes in pain between the 1- and 3-year assessments, but the reduction of pain was still significant (p < 0.001) compared with preoperative scores. The same applied for the patients' subjective problems, with no statistically significant changes between the 1- and 3-year assessments. Thus, the initially scored postoperative improvement (p < 0.001 for all items except sleep) remained. Three years after the operation, the patients' preoperative expectations were still fulfilled. There were minor differences between the 1-year and the 3-year health-related quality-of-life scores (Short Form-36), but these were all without statistical significance. Compared with preoperative scores, major improvement was still found for all sub-scales (p < 0.05 to p < 0.001) except "role physical." Reduction mammaplasty is an efficient remedy for pain and physical and psychological problems associated with macromastia. The improvements noted directly after the reduction mammaplasty remain stable and are, as judged by patient questionnaires and quality-of-life scores, of long-standing clinical importance.     

A Z-mammaplasty with minimal scarring

An improved technique for reduction mammaplasty is described that has the advantage of giving a satisfactory final shape to the breast while producing a minimal scar. The method involves periareolar deepithelialization with displacement of the nipple-areola complex, partial subcutaneous mastectomy at the base of the mammary cone, and a Z-plasty to interlock two triangles of skin left after the removal of a little excess skin in the region above the inframammary fold. The Z-plasty adds skin vertically to the inferior pole, resulting in a better final shape and reducing tension around the areola. Any further excess skin is left to retract spontaneously. The best indications for this operation are in young women with elastic skin free of striae "gravidarum." Our experience now covers 53 patients aged 14 to 30 years with reductions of up to 900 gm per breast, and we have encountered no major complications over a 3-year follow-up period.     

Cryopreserved autologous nipple-areola complex transfer to the reconstructed breast

If a patient's nipple-areola complex is available for grafting after mastectomy, it is the best material to use for nipple-areola reconstruction. The authors performed delayed autologous nipple-areola complex transfer to reconstructed breasts in 10 patients (mean age, 47 years; range, 40 to 53 years). The nipple-areola complex was cryopreserved with a programmed freezer after mastectomy. Histological examination of the tissue surrounding the nipple and areola eliminated the possibility of cancer invasion. At the time of transfer, the cryopreserved nipple-areola complex was thawed in 37 degrees C water and grafted on a projection made by a denuded dermal flap on the reconstructed breast. Each patient underwent immediate breast reconstruction using an innervated pedicled transverse rectus abdominis musculocutaneous (TRAM) flap. The patients' postoperative courses were uneventful. The timing of transfer ranged from 3 months to 1 year (mean, 5.8 months) after breast reconstruction. Nipple projection was made by the "four" dermal flap in five cases, a round dermal flap in three cases, a double dermal flap in one case, and a denuded skate flap in one case. The follow-up period ranged from 5 to 36 months (mean, 21.8 months). All grafts were adapted. The final evaluation of nipple-areola complex adaptation was good in four cases, fair in four cases, and poor in two cases. Histological examination of the hematoxylin and eosin stains showed no remarkable destruction of the skin of the nipple and areola, and electron microscopic examination of the areola skin revealed no significant change. However, electron microscopic examination of the nipple skin showed serious damage to skin components, including elongation of the desmosome, widening of the intercellular space at the prickle cell and basal layers, and shrinking of prickle and basal cells. Although further development of the freezing process and cryopreservation technique is needed to prevent depigmentation of the nipple and areola, cryopreserved nipple-areola complex transfer to a reconstructed breast could be an alternative method of nipple-areola reconstruction.     

Repeat reduction mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.     

Modified technique for nipple-areolar reconstruction: a case series

SUMMARY: Thousands of women undergo postmastectomy breast reconstruction each year. Part of the reconstruction of an aesthetically pleasing breast is a high-quality nipple-areolar reconstruction. The goals for this reconstruction include appropriate nipple projection, areolar color, and areolar texture. Presented in this article is a novel technique that achieves these goals without the need for harvesting a distant skin graft. The nipple-areolar reconstruction is performed under local anesthesia. A skate flap is designed to achieve the nipple reconstruction. The skate flap donor sites are closed primarily, and the outline of the areola is then defined with a round template. The skin is then incised at the border of the areola, and a full-thickness graft is elevated to the base of the reconstructed nipple. After hemostasis is achieved, the skin graft is placed back down in its original position and a bolster dressing is applied. Tattooing is performed 4 months postoperatively to achieve a color match. Twenty-four consecutive patients underwent 31 nipple-areolar reconstructions using this novel technique. All patients achieved excellent results without complications. One patient did experience a partial skate flap loss; however, the wound healed secondarily without the need for revision. The technique described herein can achieve the goals of nipple-areolar reconstruction, including appropriate nipple projection, areolar color, and areolar texture, without the need for a distant skin graft.     

Integrated breast mound reduction and nipple reconstruction with the wraparound flap.

A new method for nipple reconstruction is described that combines revision of an autologous tissue breast mound with creation of a projecting nipple. The method is applicable only to reconstructed breast mounds that must be reduced or lifted to achieve symmetry with the opposite breast. In this technique, the mound is reduced as if it were a normal breast, using an inverted-T or vertical mammaplasty pattern. In this way, breast projection can be increased and, if necessary, the inframammary fold can be elevated. A rectangular flap is created from skin and subcutaneous tissue that would normally be discarded during the breast reduction, and this flap is wrapped around on itself to form a projecting nipple. This new technique avoids the flattening of the breast mound usually seen after nipple reconstruction because it does not take tissue away from the completed breast mound to make the nipple. In appropriate patients who require reduction in size of their reconstructed breast mound, the wraparound flap nipple reconstruction is worth considering.     

Cosmetic and reconstructive breast surgery in blacks

Black women have not embraced cosmetic and reconstructive surgery of the breast with the same enthusiasm as their Caucasian counterparts because of fear of hypertrophic scars. The authors offer suggestions on how to minimize the scarring associated with breast surgery in black women. They feel that intraareolar incisions should be used whenever circumareolar incisions are indicated in augmentation mammaplasty, because the areola, being a favored area, is less likely to produce hypertrophic scars. The Marchac technique of reduction mammaplasty is recommended because it produces a short horizontal scar of 5 to 8 cm confined to the breast without medial and lateral extension, which may hypertrophy in black women. In the reduction of large breasts, secondary excision of dogears 6 or more weeks after mammaplasty reduces the medial and lateral extents of the scar. The use of liposuction as an adjunct to reduction mammaplasty may also accomplish the same thing. Amputation and free nipple-areola grafting should be used with caution in black patients because of the tendency of the grafted areola to hypopigment. In postmastectomy reconstruction, the authors suggest that the techniques described by Ryan and Radovan should be considered first before the techniques of reconstruction utilizing myocutaneous flaps. In these procedures, no new scars which may hypertrophy are created away from the site of reconstruction. Staples should not be used in skin closure in blacks because they cause cross-hatching of the wound even when removed early.     

即时扩展型背阔肌肌皮瓣乳房再造在保留乳头乳晕复合体乳癌术后的运用分析

目的：探讨分析即时扩展型背阔肌肌皮瓣乳房再造在保留乳头乳晕复合体乳癌术后的运用。方法：回顾性分析我院2008年2月-2012年4月收治的乳腺癌术后患者106例,采用乳癌术即时扩展型背阔肌肌皮瓣乳房再造保留乳头乳晕复合体,观察手术效果以及满意度。结果：术后患者乳房美容优良率为88．68％明显大于对照组的47．17％,并且术后6个月治疗组生活质量评价总分明显大于对照组总分术后6个月患者生活质量评价总分明显大于术前评价总分,差异具有条件下意义（P〈0．05）,差异均具有统计学意义（P〈0．05）。结论：即时扩展型背阔肌肌皮瓣乳房再造在保留乳头乳晕复合体乳癌术后患者乳房美容效果较好,提高患者生活质量高,值得在临床上推广,但在手术后需积极处理可能存在的并发症情况。     

Outcome analysis of reduction mammaplasty using the modified Robertson technique

The benefits of reduction mammaplasty have been well documented in previous literature. Anticipating and correcting for pseudoptosis (bottoming-out), however, can impair the cosmetic outcome as the inferior skin envelope stretches and lengthens over time. We present long-term results on patients using the modified Robertson technique for reduction mammaplasty, which appears to have significant benefit in helping to prevent bottoming-out. Surveys were sent to patients undergoing reduction mammaplasty surgery with this technique from 1987 to 1997. Patients were queried regarding preoperative and postoperative symptoms, satisfaction, and outcome related to their surgery and were also offered free follow-up examinations. The patients who returned for follow-up were then evaluated by the attending surgeons for evaluation of scarring, nipple position, ptosis, pseudoptosis, shape, and overall appearance. Reduced breasts were also compared with cosmetically optimal breasts to compare for measured levels of pseudoptosis using our defined visual inferior pole ratio measurements. Average reduction size was 910 g and follow-up was 4.7 years from the time of surgery. There was significant improvement demonstrated in all areas questioned, with the greatest relief shown in back and shoulder pain, shoulder grooving, and difficulty fitting clothing. There was also demonstrated to be significantly less use of medical modalities postoperatively and significant increases in activity levels. Satisfaction for size, shape, symmetry, and overall results was 85, 94, 98, and 94 percent, respectively. Evaluations for pseudoptosis by the attending surgeons were rated good or excellent in 95 percent of patients. Measurements of the visual inferior pole ratio for pseudoptosis also demonstrated no significant differences when compared with aesthetically optimal breasts. The modified Robertson reduction mammaplasty is a reliable technique that can be used for both small and large reductions, giving both reliable and consistent results. This technique significantly improves symptoms, as do other reduction techniques, but has the added advantage of helping to avoid pseudoptosis postoperatively.     

Reconstruction of the burned nipple-areola complex

Reconstructive results of 115 burned nipple-areola complexes in 84 female patients were reviewed. Results of nipple reconstruction using local quadrapod flaps (33 percent good, 45 percent fair, 22 percent poor) and composition grafts from the earlobe (20 percent good, 60 percent fair, 20 percent poor) were comparable, and both were superior to results obtained with the "double-bubble" technique (24 percent good, 35 percent fair, 41 percent poor). Differences in nipple reconstruction techniques were not appreciated until 1 year postoperatively. The early appearance of areola reconstruction with tattooing and split-thickness grafts was excellent. However, significant late hypopigmentation changes were observed with both techniques. Areola reconstruction with full-thickness skin grafts from the superomedial thigh (47 percent good, 33 percent fair, 20 percent poor) were superior to those obtained with tattooing (14 percent good, 35 percent fair, 51 percent poor) and split-thickness skin grafts from the contralateral unburned areola (21 percent good, 21 percent fair, 58 percent poor). We recommend employing local quadrapod flaps (for nipple), provided there is adequate surrounding dermis, and full-thickness skin grafts (for areola) in the reconstruction of the burned breast.