Extended applications of the carbon dioxide laser for skin deepithelialization

The efficacy of the carbon dioxide laser for skin deepithelialization in humans was initially demonstrated using reduction mammaplasty as a clinical model. Twenty-two additional successful cases including use of this technique as an adjunct for other flap transpositions and overgrafting of skin grafts are described. These results document a role for the carbon dioxide laser in skin deepithelialization, where it provides an advantage when rigid skin immobilization is impossible or if there would be a risk to underlying structures if more conventional approaches were used.     

Laser deepithelialization: an adjunct to reduction mammaplasty

A new use is described for the CO2 laser--that of deepithelialization. Deepithelialization is a technique used in a myriad of plastic surgical procedures. This paper introduces the use of the laser for deepithelialization and illustrates its advantages in 44 consecutive patients undergoing reduction mammaplasty. Advantages are the precise removal of the upper dermis and epidermis--a true deepithelialization--with preservation of the lower dermis and pilosebaceous units. Associated decreased blood loss and more rapid operating time without an increase in complications makes this an attractive adjunctive technique with a wide variety of applications. No adverse effects or contraindications to the use of the CO2 laser for deepithelializing have been found.     

Reduction mammaplasty using the inferior glandular "pyramid" pedicle: experiences with 300 patients

A comprehensive review of 300 patients undergoing reduction mammaplasty (576 breasts) based on an inferior glandular pedicle is presented. The average age was 31.7 years, weight 146.6 lbs., and the amount of tissue removed 1313.6 gm. No deepithelialization of the skin was performed, and average operating time was 174 minutes. The average distance the nipple-areola complex was moved was 12 cm, with the longest being 22.5 cm. Fifty-seven percent had fibrocystic mastopathy on histologic analysis, and no malignancies were found, even in patients who had undergone a previous mastectomy for breast carcinoma. The most common complication (3.1 percent) was minor suture line necrosis along the infra-mammary crease. All healed without intervention. There was no necrosis or sensory loss to the nipple-areola complex in any patient, and cosmesis was excellent. The analysis also showed that the use of epinephrine, injected subcutaneously just prior to the operation, significantly decreased intraoperative blood loss (p less than 0.0005), regardless of the amount of tissue removed, and eliminated the need for transfusions.     

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.     

Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty

A method of breast reduction is presented that maintains the blood supply and innervation to the nipple and areola complex by means of an inferior pedicle, reduces the breast volume by removing tissue from the periphery of the breast, maintains breast shape with internal plication sutures, and limits the scar using a periareolar technique with a short inferior vertical-to-oblique extension. There were 167 breasts in 98 patients reduced in this fashion. The average resection volume was 632 g per breast, with an average follow-up of 7.6 months. The complication rate was similar to that observed using traditional inferior pedicle techniques with the inverted-T cutaneous scar. This technique has proven to be versatile, technically straightforward, and applicable to breasts of all sizes for both breast reduction and mastopexy. By combining the aesthetic advantage of less cutaneous scarring with the safety and familiarity of the inferiorly based pedicle, superior results in breast reduction can be obtained that are consistent, long-lasting, and satisfying for both patient and surgeon alike.     

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.     

Medial pedicle reduction mammaplasty for severe mammary hypertrophy

Current options in reduction mammaplasty for severe mammary hypertrophy include amputation with free-nipple graft as well as the inferior pedicle and bipedicle techniques. Complications of these procedures include nipple-areola necrosis, insensitivity, and hypopigmentation. The purpose of this study was to determine whether medial pedicle reduction mammaplasty can minimize these complications. Twenty-three patients with severe mammary hypertrophy were studied. The medial pedicle successfully transposed the nipple-areola complex in 44 of 45 breasts (98 percent). Mean change in nipple position was 17.1 cm, and mean weight of tissue removed was 1604 g per breast. Nipple-areola sensation was retained in 43 of 44 breasts (98 percent) using a medial pedicle. Hypopigmentation was not observed, and central breast projection was restored in all patients. This study has demonstrated that medial pedicle reduction mammaplasty is a safe and reliable technique and should be given primary consideration in cases of severe mammary hypertrophy.     

Superomedial pedicle technique of reduction mammaplasty

A series of 148 patients who underwent reduction mammaplasty utilizing the superomedial pedicle technique is presented. Resections as large as 4100 gm per breast with nipple-areola transpositions up to 30 cm were done with reliable nipple-areola survival, including preservation of sensation. The superior pedicle technique of breast reduction is recognized by many as technically easier and capable of producing a longer-lasting aesthetic effect. Classically, however, it has been limited to smaller resections. By incorporating the medial quadrant in the superior pedicle, more aggressive reductions can be safely undertaken with the same excellent results. Details of the procedure, the anatomic basis for its success, and complications are discussed.     

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.     

Arch reduction mammaplasty

Arch mammaplasty is a breast reduction technique based on the inferior pedicle. It uses all the specific advantages of the inferior pedicle while avoiding the inframammary scars and dead space that occur with the inverted T technique. Arch mammaplasty has proven versatile and extremely safe, and it has a surprisingly good rate of acceptance by the patients. The scarring is aesthetically superior to that obtained with the well-accepted, inverted-T scar technique of the past.     

The pure posterior pedicle procedure for breast reduction

The inferior pedicle technique, which has already become classic, employs a glandular areola-bearing pedicle whose source of vascularization is primarily posterior. In fact, the inferior pedicle is a posterior pedicle with an inferior border. After systematically and progressively reducing this inferior border, I have completely eliminated it. The pure posterior pedicle that results is independent of the inframammary fold. It is vascularized by means of the pectoral muscle and fascia, as has been demonstrated by injection studies of the thoracoacromial artery in fresh cadavers. The resulting mammary reduction technique retains the advantages of the inferior pedicle technique while avoiding its major inconveniences: dependence on the inframammary fold, bulging at the inferior base of the pedicle, and the necessity of low positioning for the breast.     

Secondary reduction mammaplasty: is using a different pedicle safe?

Reduction mammaplasty is a frequently performed procedure and one with consistent patient satisfaction. Few patients present for revisional procedures, and even fewer present for a secondary or repeated reduction mammaplasty. This study defines secondary reduction mammaplasty as performing an additional reduction using a pedicled nipple-areola complex. Few reports of secondary reduction are found in the literature. Operative guidelines for secondary reduction mammaplasty have been published recently. However, the experience of others has differed from these guidelines, and herein is presented another experience with secondary reduction mammaplasty. Ten cases of secondary reduction over a 37-year period were identified and reviewed. The initial reductions were performed using six different techniques. An average of 307 g of tissue per breast (range, 130 to 552 g) was removed at the initial operations. The secondary reductions were performed using four different techniques, and an average of 458 g of tissue per breast (range, 147 to 700 g) was removed at the secondary operations. Three of the 10 patients underwent initial and secondary reduction with the same technique. An average of 4 years (range, 1 to 10 years) separated these surgeries. Seven of the 10 patients underwent initial and secondary reductions with different technique. An average of 15 years (range, 5 to 19 years) separated these procedures. There was an average 5-year follow-up (range, 1 to 20 years) in this series. Four of the 10 patients experienced self-limiting complications after secondary reduction, including delay in wound healing, delay in the return of nipple sensitivity, and mild fat necrosis. Three of the four patients with complications had undergone secondary reduction with a different pedicle technique. No significant or long-lasting skin, pedicle, or nipple-areola complex compromise was found after secondary reduction mammaplasty. In contrast to the recently published guidelines, this study demonstrates that secondary reduction mammaplasty is a safe and viable option when performed with either similar or different technique. This finding allows secondary reduction mammaplasty to be tailored to the individual breast type and to the abilities of the specific surgeon.     

Heel coverage with a deepithelialized distally based fasciocutaneous flap

A distally based fasciocutaneous flap for heel coverage is reported. Its blood supply depends on distal septocutaneous perforators interconnected with the suprafascial plexus. A "turn-down" transposition and distal deepithelialization were utilized to avoid kinking of the pedicle. After a 1-year follow-up, it has provided stable coverage with normal function.     

The role of vasoconstrictors in control of blood loss in reduction mammaplasty

Because blood loss has been a concern in reduction mammaplasty, a prospective double-blind study was undertaken to determine whether instillation of an epinephrine solution into the breast parenchyma would reduce blood loss during this procedure. the inferior glandular pedicle technique was used with each patient serving as her own control. A significant reduction in operative blood loss compared with the control solution was observed. We believe that instillation of an epinephrine solution should be a routine part of the reduction mammaplasty procedure.     

Reduction mammaplasty with a circular folded pedicle technique.

A personal technique for breast reduction utilizing a circular dermal-breast pedicle is presented. After a cutaneous glandular excision in the inferior pole and glandular excision in a discoid shape under the central area, the pedicle is folded on itself to produce a direct elevation of the nipple-areola complex into its new position, to enhance projection, and to act as a central support. A rational economy of scars is obtained by a central convergence of the breast tissue that stretches the breast periphery and by sutures finishing in the inferoareolar area. There the skin excess is removed to avoid scar lengthening in both the caudal and cranial directions. Evaluation of long-term results reveals maintenance of breast projection, preservation of the inframammary fold to inferior areola distance, and minimal residual scarring.     

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.     

Breast reduction

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the preoperative considerations that must be weighed to appropriately assess operative risk of breast reduction. 2. Have a full understanding of the basic techniques that are available to treat the patient with macromastia. 3. Identify which patients are best suited to a particular technique. 4. Identify common complications associated with breast reduction and understand how to treat them. SUMMARY: Breast reduction remains a basic plastic surgery procedure designed to alleviate upper torso complaints resulting from macromastia. Historically, the inverted-T inferior pedicle procedure was the dominant technique for the treatment of macromastia for 40 years. The past two decades have seen a reexamination of breast reduction technique in an attempt to improve on the results and minimize complications. As a result, a new genre of procedures based on different pedicles and short-scar skin management techniques has been introduced. With these new procedures, the plastic surgeon now has a variety of different techniques that can be offered for reducing the hypertrophic breast. Strategically applying the concepts inherent in these procedures to the correct patient can provide outstanding results with few complications. In this article, the concepts and results of these various procedures are discussed to give the reader a basic understanding of the options available for breast reduction.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

A comparison of two methods of infiltration in breast reduction surgery

The superwet technique has been shown in previous studies to dramatically reduce blood loss in breast reduction surgery, compared with standard infiltration. A retrospective chart review of 303 consecutive patients undergoing bilateral breast reduction surgery was undertaken to demonstrate additional differences in complication rate, operative time, or sponge use in the operating room. In this series, 132 consecutive patients received standard infiltration along incision lines (25 cc per breast of 1:100,000 epinephrine), and 171 patients received superwet infiltration with 240 cc per breast of 1:1,000,000 epinephrine. The average operative time was significantly reduced in the superwet group, from 78.5 minutes to 70.7 minutes (p < 0.01 level). The average number of sponges used intraoperatively was also decreased significantly (p < 0.01), from 26 to 20 sponges. Complication rates were equally low in both groups, demonstrating the safety of the superwet technique. In addition to limiting blood loss, the superwet infiltration effectively reduces operative time and sponge use without increasing complications in breast reduction surgery.     

A comparison of complication rates in large and small inferior pedicle reduction mammaplasty

The main objective of this retrospective study was to determine whether the rates of complications are higher in large reductions (> or =1000 g per breast) as compared with smaller reductions (< or =999 g per breast) using the inferior pedicle technique. A retrospective chart review of 133 consecutive patients operated on between October of 2000 and March of 2002 was undertaken. Complication data were recorded and analyzed on a per-breast basis. Two hundred sixteen breasts had reductions of 999 g or less, whereas 50 breasts had reductions of 1000 g or more. The overall mean follow-up period was 152 days (range, 20 to 522 days). There were no statistically significant differences in the rates of nipple necrosis, hematoma formation, seroma, delayed healing, culture-positive wound infection, fat necrosis, cyst formation, nipple sensation, or hypertrophic scarring between the large and small reductions. However, the rate of wound dehiscence was significantly lower in the smaller reduction group. The rates of wound dehiscence and hypertrophic scarring were also significantly lower in patients who had received at least 5 days of postoperative antibiotics. A statistically significant difference was also reported for clinical wound infection (p < 0.0005). Body mass index had no statistically significant effect on the rate of nipple necrosis, hematoma formation, fat necrosis, cyst formation, nipple sensation, or hypertrophic scarring. However, body mass index had a statistically significant effect on delayed healing, wound dehiscence, and culture-positive wound infection. A higher mean body mass index predicted a delayed healing, wound dehiscence, and infection. The inferior pedicle technique is a safe method of breast reduction regardless of degree of parenchymal resection. However, the use of postoperative antibiotics for at least 5 days is recommended to reduce rates of wound dehiscence and improve postoperative scarring.