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.     

Reduction mammaplasty in postburn breasts.

Thermal injury to the anterior chest in the adolescent girl can lead to severe disfigurement of the breasts. Just as in certain non-burn female patients, mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. Most plastic surgeons have been reluctant to perform reduction mammaplasty in these patients for fear of devascularizing the skin graft or the nipple-areola complex. A series of six patients with full-thickness burns of the breasts and subsequent skin graft coverage before reduction mammaplasty is reported. Four patients had bilaterally burned breasts requiring reduction. Two patients had one burned breast reduced, and one required a balancing procedure on the unburned side. Reduction mammaplasty was performed using the inferior-pedicle technique. The mean amount of tissue removed for the left and right breasts was 454 and 395 g, respectively. There was no nipple loss, hematoma, infection, or major loss of skin flaps. Reduction mammaplasty in this group of patients is safe and carries minimal risk if certain key concepts are followed carefully.     

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.     

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.     

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.     

The vertical mammaplasty: a reappraisal of the technique and its complications

Since 1989, superior pedicle vertical scar mammaplasty as described by Lejour has been used in the authors' department as the only technique for breast reduction. From 1991 through 1994, a series of 170 consecutive patients (330 breasts) underwent an operation. In these patients, minor complications were observed in 30 percent of the patients and major complications in 15 percent. Surgical revision for scar or volume corrections was necessary in 28 percent of the breasts, which seemed unacceptable. Therefore, the original technique was modified by decreasing the skin undermining and avoiding liposuction in the breast. Primary skin excision was performed in the submammary fold at the end of the operation if the skin could not be puckered adequately. This modified technique was used from 1996 through 1999 in 138 consecutive patients (227 breasts). In the second series, minor complications were observed in 15 percent of the patients and major complications in 5 percent. However, the technical modifications did not significantly change the rate of secondary scar and volume corrections, which were still necessary in 22 percent of the breasts. In large breasts, the addition of a horizontal scar at the end of the operation did not change the rate of secondary revision, which however compares favorably with the figures obtained with the inverted T, superior pedicle mammaplasty.     

Reduction mammaplasty with superior-lateral dermoglandular pedicle: another alternative

During a period of 7.5 years, reduction mammaplasty using a superior-lateral dermoglandular pedicle was performed in 213 mammary glands in 112 patients. This procedure is a modification of the original technique by Skoog that takes advantage of its benefits but adds two basic premises: (1) to preserve the integrity of the galactophorous ducts for future nursing and (2) to cause less innervation injury. Patients were followed for an average of 28 months (range, 3 months to 7.5 years). The quantity of extirpated tissue ranged from 310 to 1380 g, with a median of 520 g. The nipple-areola complex migrated 5 to 14.5 cm (median, 7.8 cm). The most severe complication was partial necrosis of the nipple-areola complex, which occurred in five cases (four patients). This complication occurred only during the first 2 years of the study, in breast resections larger than 800 g, and with migrations larger than 10 cm. This problem resulted in a modification of the technique, and the complication has not occurred for the past 5 years. There were no important alterations in the sensibility of the nipple-areola complex nor in the integrity of the galactophorous ducts. The long-term satisfaction of the patients was high. The authors present an easily designed and accomplishable technique that is applicable to patients with severe hypertrophy and gigantomastia. The technique has a high security index, and the integrity of the mammary gland is maintained to the maximum.     

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.     

Simplifying the vertical reduction mammaplasty

The vertical reduction mammaplasty is an evolving technique. Its proponents report significantly decreased scarring, better breast shape, and more stable results compared with the standard inverted-T method, but the learning curve is long and cosmetic outcomes can be inconsistent. Many surgeons have experimented with the vertical closure before returning to methods more familiar to them. The authors present their modifications to the vertical reduction mammaplasty. Their changes simplify the preoperative markings and the intraoperative technique to shorten the learning curve while maintaining reliable aesthetic results. With the patient standing, only four preoperative marks are made: (1) the inframammary fold; (2) the breast axis; (3) the apex of the new nipple-areola complex; and (4) the medial and lateral limbs of the vertical incision. In the operating room, a medial or a superomedial pedicle is developed. Excess breast skin is resected with the inferior and lateral parenchyma as a C-shaped wedge. The lateral skin-adipose flap is redraped inferomedially and sutured to the chest wall. The inferior aspect of the breast is aggressively debulked and a gathering subcuticular stitch is started 2 cm below the nadir of the nipple-areola complex. Finally, a 38-mm to 42-mm nipple-areola complex marker is used to create a circular defect that is offset 0.5 cm medial to the vertical axis of the breast. In their series, 56 patients were treated and no major complications were noted. The median follow-up period was 17 months. The average reduction was 554.5 g per breast; however, the reduction was greater than 1000 g per breast in eight patients. The authors found that (1) chest wall anchoring improves lateral contour and minimizes axillary fullness; (2) aggressive debulking inferiorly avoids the persistent inferior bulge; and (3) starting the subcuticular gathering suture 2 cm below the nipple-areola complex followed by placement of a nipple-areola complex marker at the conclusion of the case prevents lateral deviation and corrects the nipple-areola complex teardrop deformity. These innovations accelerate the learning curve by simplifying the preoperative markings and lead to more consistent postoperative results and an improved cosmetic outcome. In conclusion, these modifications yield a simple, easily learned vertical reduction mammaplasty with aesthetically reliable results.     

Carpal tunnel syndrome in women undergoing reduction mammaplasty

Women with mammary hypertrophy who present for reduction mammaplasty have several well-described musculoskeletal complaints, but a high prevalence of carpal tunnel syndrome has not been reported. We identified 151 patients from a plastic surgery practice who underwent reduction mammaplasty from 1994 to 1996. To this group we added a convenience sample of 64 women volunteers with relatively smaller breasts (brassiere cup size B or smaller). We questioned the entire group about specific symptoms and examined them using standard provocative tests. Carpal tunnel syndrome was defined as the coexistence of symptoms and at least two physical examination findings. We examined its association with breast size, age, race, and body mass index. Stepwise logistic regression was used to determine which physical characteristics were predictive of the condition. Carpal tunnel syndrome was found in 30 patients (19.9 percent) (95 percent confidence interval, 13.8 to 27.1) and in none of the women in the convenience sample. Breast size and, to a lesser degree, body mass index were found to be highly significant predictors of carpal tunnel syndrome. After controlling for breast size, race was also significant. Breast size displayed an independent risk ratio of 6.67 when comparing the upper quartile of size to the lower quartiles. There is a markedly higher prevalence of carpal tunnel syndrome in women who present for reduction mammaplasty than in those with smaller breasts. Breast size was a significant predictor of carpal tunnel syndrome.     

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.     

Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry

A variety of breast deformities of differing appearances can be grouped together within an extensive syndrome that is characterized by anomalies of the breast base and preferentially involves the lower quadrants. Tuberous breasts are the most typical, but not the only, form of the deformity. The authors studied a series of 37 patients who had breast surgery, and they used a classification of three types: I, II, and III (in increasing order of severity). In type I breasts (minor form), only the lower medial quadrant is deficient; in type II breasts, both lower quadrants are deficient; and in type III breasts, all four quadrants are deficient. The study showed a predominance of minor forms (54 percent of breasts operated on) and of combinations including at least one minor form (81 percent of patients). Seventy percent of women had a breast asymmetry of more than 100 g. Only 27 percent of breasts operated on were hypotrophic, 45 percent were of normal volume, and 28 percent were hypertrophic. The authors propose a procedure to treat the minor forms of the deformity, using a mammaplasty with a superior pedicle and a lower lateral dermoglandular flap to fill the deficient lower medial quadrant. They define the indications of the classic techniques according to the type of deformity and stress the frequent need for secondary revision.     

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.     

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-feeding after vertical mammaplasty with medial pedicle

A retrospective study was performed in which the breast-feeding success of women of childbearing age (15 to 40 years) with macromastia but no prior breast surgery was compared with that of women of similar age who had undergone medial pedicle/vertical pattern reduction mammaplasty. All women completed a self-administered questionnaire that provided information on their breast-feeding success. The control group consisted of 149 women with macromastia (mean age, 27 years) who had been evaluated for possible breast reduction surgery and who had children before their consultation. The study group consisted of 58 women (mean age, 29 years) who had children after their vertical mammaplasty. The mean weight of breast tissue removed was 610 g per breast. None of the patients had absent nipple sensation. A period of 2 weeks or more was chosen as the defining duration of a successful breast-feeding attempt. Those individuals judged able to breast-feed were further classified on the basis of having breast-fed exclusively or with supplementation. The results demonstrated that, of the women who attempted to breast-feed, 61 percent in the control group and 65 percent in the study group were successful, with no significant difference between the groups (p > 0.05). The breakdown of the successful groups indicated that 36 percent in the control group and 38 percent in the study group supplemented their breast-feeding with formula. The groups were not significantly different (p > 0.05). In conclusion, this study found no significant difference in the rate of breast-feeding success between women who had medial pedicle/vertical pattern reduction mammaplasty and women who had no prior breast surgery.     

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.     

Elimination of the vertical scar in reduction mammaplasty.

We describe a technique to eliminate the vertical portion of the inverted-T incision in patients who have combined enlargement of the breasts and moderate to severe ptosis. Initial preoperative markings are made, placing the new nipple site at the level of the transposed inframammary crease. The nipple-areola complex is then retained on a vascularized pedicle, with major reduction of the breast tissue being done in the medial and lateral quadrants. The nipple and breast tissue are then tucked underneath the superior skin segment and placed in this new position as one would do with the umbilicus in an abdominoplasty. Excess vertical skin is removed, and horizontal excess is collected at the midline as a small dog-ear. We have found that this dog-ear reduces markedly with time, rounding out the inferior portion of the breasts. The remaining small amount of excess skin can then be removed under local anesthetic at a later date. We have performed this procedure on 20 patients, with follow-up from 6 to 24 months.     

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.     

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.     

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.