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.     

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.     

A method of reconstructing a pendulous breast utilizing the tissue expander

It is possible to reconstruct a breast mound of almost any size by utilizing tissue expansion. In order to produce a pendulous breast which is also ptotic, the tissue-expansion technique has been combined with two other procedures. A new technique is being introduced. It is that of elevating the lower third of the mature breast capsule surrounding the tissue expander at the time the permanent prosthesis is to be exchanged for the expander. The established techniques of inframammary fold reconstruction of Pennisi and Ryan are used to provide pedicle skin coverage for the undersurface of the breast and the bed of the elevated capsule. Internal and external surgical approaches are described, and two examples of each are illustrated. Breasts reconstructed in this manner have remained pendulous structures. Some loss of the initial degree of ptosis has been noted in some cases.     

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.     

Short-scar breast reduction: why all the fuss?

The breast can be considered conceptually as a cone. This article compares and contrasts short-scar breast reduction techniques with inverted T techniques using the cone model. Four issues are examined-the base of the breast, breast projection, the inframammary fold, and the pedicle. The short-scar techniques focus on reshaping the breast parenchyma, and skin redraping occurs secondarily. Application of this model suggests that these techniques have the advantage of better projection and greater longevity. These techniques seldom give a square shape and are better at dealing with upper pole deficiency. However, the ability of the skin to redrape is the limiting factor; hence, results are less predictable with large-volume breast reductions. The emphasis of this article is on increasing the understanding of the mechanics of breast reduction. It is this factor that will enable appropriate selection of a particular technique.     

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.     

Toward a more natural breast: the interpolated thoracoepigastric pedicle in breast reconstruction

A method of reconstructing the breast mound after mastectomy using a superiorly based thoracoepigastric pedicle is presented. The advantages of the method are its relative simplicity and its definition of the inframammary fold. It often obviates the need for inflatable expanders. The prime disadvantage is the scar left on the abdominal donor site.     

An improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy

Subcutaneous mastectomy is becoming an operation of choice in certain cases of premalignant and other breast pathology. We describe a technique for simultaneous subcutaneous mastectomy and retropectoral implantation of a silicone prosthesis. Gentle blunt prepectoral, retromammary dissection is performed through an axillary incision as far inferiorly as the inframammary fold, where a fibrous bridge between the anterior surface of the pectoralis major muscle and the skin prevents dissection any lower. Through the same incision, the retropectoral space is dissected to about 5 cm below the inframammary fold. A second incision is made in the inframammary fold to join the retromammary plane of the first dissection. The gland is then dissected subcutaneously and removed through the inframammary incision. A silicone implant is introduced retropectorally through the axillary incision, thus avoiding splitting the pectoralis major. Satisfactory results have been obtained in 23 bilateral and 14 unilateral cases; it is important that the dissection be performed carefully in order to prevent the implant from riding up too high in its musculoaponeurotic sling.     

Staged use of soft-tissue expansion and lower thoracic advancement flap in breast reconstruction

A single patient is presented in whom breast reconstruction after mastectomy for breast cancer has been achieved by sequential use of soft-tissue expansion followed by permanent silicone implant placement and thoracic flap advancement to define the inframammary fold. This procedure may play a useful role in patients in whom other, more complex methods of breast reconstruction are not selected or indicated and in particular in patients in whom bilateral silicone implants are utilized.     

Reduction mammaplasty with the "owl" incision and no undermining

Reduction mammaplasty has traditionally been done using the Wise pattern of incision. Because of the box-like effect in breast shape, the lack of projection, and the long scars associated with the inverted T incision, two techniques have emerged as alternatives: the vertical reduction of Lassus/Lejour and the "round block" periareolar technique popularized by Benelli. Each of these techniques has its pros and cons.The "owl" incision combines the features of the large periareolar reduction (Benelli's) and the vertical reduction (Lassus/Lejour); the horizontal inframammary scar is either made very short or completely eliminated. Volume reduction is done through a heart-shaped parenchymal resection, leaving the nipple-areolar complex over a supero-central pedicle. Maintenance of the central parenchyma behind the nipple-areolar complex and mobilization of the vertical pillars toward the center of the breast give excellent projection and diminish the lateral fullness. Enlargement of the periareolar skin resection diminishes the length and pleating of the vertical scar; conversely, inclusion of the vertical component to the periareolar technique eliminates the pleating effect of the periareolar incision. The short horizontal excision eliminates any resultant "dog ears" in the new inframammary fold. Thus, the discrepancy in the length of scars is better distributed. There is no skin or parenchymal undermining, so drains are not needed. Excellent results are obtained immediately on the operating table, and large volumes of glandular resection and correction of severe ptosis can be accomplished without compromising vascularity of either the nipple-areolar complex or the skin flaps.Ninety-four patients in a 7-year period were operated upon using this technique. Seventy-two had bilateral reductions up to 1900 gm per breast, 12 had unilateral reduction for symmetry following breast reconstruction, and 10 were patients with severe ptosis. Complications were rare and of a minor nature. No conversion to free grafts was done, even in the larger resections. One case required minor revision under local anesthesia, one case required bilateral re-reduction, and another case required unilateral re-reduction for continued growth of breast tissue. Almost 90 percent of the patients underwent procedures as outpatients.The owl-type incision and the supero-central pedicle flap are elements of a reduction mammaplasty technique that provides excellent projection and shape with minimal visible scars. It takes advantage of the positive features of the periareolar and vertical reduction techniques and minimizes their negative features. The new design of parenchymal resection improves the vascularity of the residual flaps. Additionally, it may better preserve the sensation to the nipple-areolar complex and lactation is not compromised.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

Breast reconstruction with the internal mammary artery pedicled fasciocutaneous island flap: description of a new flap

Postburn skin contracture of the inframammary sulcus is a commonly encountered problem, especially in pubescent girls. Release of these contractures is commonly performed by split-thickness skin grafts, which necessitate further operations as the child grows. If the contracture of the inframammary sulcus is only one-sided, then the inframammary tissues of the contralateral breast can be used for reconstruction with the fasciocutaneous island flap. The donor site can be closed primarily without disrupting the appearance of the healthy breast, and the skin incision is hidden in the inframammary sulcus. The flap described here is a fasciocutaneous island flap based on the internal mammary artery and the perforating branches to the skin and subcutaneous tissues that the artery gives off as it leaves the thoracic cavity through the seventh intercostal space. After being supported by fresh cadaver and angiographic studies, the flap was applied to seven female patients (four of whom were pubescent) with burn contracture of the breast; satisfactory results were obtained. In defects of the mammary region that required volume or for which repair by skin grafting was planned, in sternal defects, or in young patients, this flap seems to be the best choice.     

Precision in breast reduction

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

"Apron" flap and re-creation of the inframammary fold following TRAM flap breast reconstruction

To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.     

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.     

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.     

Unilateral reduction mammaplasty: sculpturing the breast from the undersurface

Various traditional mammaplasty techniques have been suggested for unilateral breast reduction, and an inverted-T incision is still the most popular approach. However, unilaterally performed traditional techniques can rarely provide long-lasting symmetry because the operated and the unoperated breasts react differently to aging, weight changes, and pregnancy. Considerable residual scarring, interference with clinical and mammographic evaluation, and limited versatility are all major drawbacks of traditional procedures. We have performed unilateral mammaplasties on 47 patients with various types of congenital and acquired asymmetries, reducing and sculpturing the breast from the undersurface by means of minimal incisions, always avoiding horizontal scarring in the inframammary crease. Through a vertical infra-areolar incision, the breast is completely detached from the underlying pectoralis fascia and hooked up, thus completely exposing the undersurface of the mammary cone. The breast can thereafter be reshaped according to the size and shape of the contralateral breast by means of a discoid resection and/or selective sectoral removal of excessive subcutaneous tissues; modifications of the basic discoid resection can increase anterior projection of the new breast mound and can change the inclination of the anteroposterior breast axis on the anterior chest wall both on the horizontal and vertical planes. The results show that if criteria for patient selection are carefully respected, the procedure can provide long-lasting symmetry with minimal residual scarring and fully preserve the breast anatomy, function, and vascularization.     

An improved technique for creation of the inframammary fold in silicone implant breast reconstruction.

A "lipo-fascial" flap is described for creation of the inframammary fold in patients undergoing breast reconstruction with silicone implants. We have employed this technique in 13 patients. The fold has been enhanced in all cases, and we have not encountered any significant complications. This technique is a useful adjunct to breast reconstruction with a silicone implant, and we recommend that it be considered in appropriate patients.     

Breast reduction utilizing the maximally vascularized central breast pedicle

Experience using a maximally vascularized central breast pedicle to nourish the nipple-areola is presented. The pedicle is designed to incorporate vascular contributions from the lateral thoracic artery, intercostal perforators, internal mammary perforators, and thoracoacromial artery by means of the pectoralis major muscle. The basic technique is as follows: First, the areola is incised and 2-cm-thick skin and subcutaneous flaps are dissected medially, laterally, and superiorly, freeing the entire central breast mound. Second, the breast is reduced in a "Christmas tree" manner, being careful not to narrow the base of the pedicle. Third, excess skin and subcutaneous tissue is excised inferomedially and laterally and the nipple is inset into proper locations. The advantages of this technique are (1) large and small reductions can be done, (2) pedicle length does not appear to be a problem, and (3) the central mound gives the forward projection needed for good contour and good aesthetic results. Sixty-five patients with follow-up to 4 years are presented.