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.     

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.     

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.     

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.     

Reduction mammaplasty: a prospective study of symptom relief and alterations of skin sensibility

The aim of the present study was to evaluate the alterations of symptoms and tactile sensibility of the breast after reduction mammaplasty. In a prospective study, 10 women were operated on using the inferior pedicle technique. The patients were examined and interviewed preoperatively and at 2 weeks and 3 and 12 months postoperatively. Tactile sensibility was assessed by Somedic monofilaments applied on nine points on each breast: the nipple, four points on the areola, and in four quadrants of the skin. Preoperative tactile sensibility was compared with tactile sensibility in 10 normal controls. A median of 744 g of tissue was removed. All patients reported relief of shoulder and neck discomfort and improvement of skin sensibility 1 year after the operation. Two weeks after the operation, the sensibility of the areola was reduced (p < 0.05), but the skin sensibility of two quadrants was improved (p < 0.05). The sensibility of the areola was restored to preoperative values during the observation period. At 12 months, sensibility was improved compared with preoperative values both in the upper part of the areola and in three quadrants of the skin (p < 0.05). Significant improvement of skin sensibility was found between 3 and 12 months postoperatively in two quadrants of the breast. Also, the erectile function of the nipple was not altered by the operation. In conclusion, the sensibility of the breast was improved or unchanged 1 year after reduction mammaplasty using the Robbins technique. Continuous improvement of sensibility was found during the 1-year observation period. The evidence provided by this prospective study rules out the common misconception that a reduction mammaplasty gives the patient reduced areola sensibility and altered erectile function.     

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.     

The prediction of breast reduction weight

Reimbursement for reduction mammaplasty has become more stringent because many insurers require specific documentation of patient symptoms and estimated weight of planned breast resection. The purpose of this study was to develop a simple, clinically useful method for predicting weight of breast tissue to be removed, using routine, easily obtained predictors (i.e., height, weight, age, measurements from sternal notch to nipple, and measurements from sternal notch to inframammary crease). Data were available from a retrospective review of 263 women undergoing reduction mammaplasty. Analyses were performed to predict resected weights obtained both in the operating room and by a pathologist for left and right breasts separately. Regression analyses showed that the sternal notch-to-nipple measurement accounted for nearly all of the explained variance in the resected weights, with correlations around 0.80 between sternal notch to nipple and resected weight. For sternal notch-to-nipple measurements > or 28.5 cm, predicted resected weights were approximately 600 g or more, and in general, 80 percent or more patients had specimen weights >500 grams. From 25.5 to 28 cm, the predicted weights ranged from about 400 to 600 g and the prediction rate of weights >500 g was 50 percent. The senior author predicted the resected breast weight to be >500 g 94 percent of the time. The equation alone did not produce an accurate prediction in the critical range, 400 to 600 g. The experienced surgeon more accurately predicted resected weights with use of practiced spatial relationship skills.     

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.     

The sensitivity of the nipple-areola complex: an anatomic study

Although preservation of the sensitivity of the nipple and areola is an important goal in breast surgery, only scant and contradictory information about the course and distribution of the supplying nerves is found in the literature. The existing controversy might be due to the difficulty in dissecting the thin nerves and to frequent anatomic variations that bias the results if only a small number of cadavers are dissected. We dissected 28 female cadavers and found that the nipple and areola were always innervated by the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th intercostal nerves. The most constant innervation pattern was by the 4th lateral cutaneous branch (79 percent) and by the 3rd and 4th anterior cutaneous branches (57 percent). The anterior cutaneous branches took a superficial course within the subcutaneous tissue and terminated at the medial areolar border in all dissected breasts. The lateral cutaneous branches took a deep course within the pectoral fascia and reached the nipple from its posterior surface in 93 percent of the dissected breasts. In 7 percent of the dissected breasts, the lateral cutaneous branches took a superficial course within the subcutaneous fat and reached the nipple from the lateral side. These findings suggest that the nerves innervating the nipple and areola are best protected if resections at the base of the breast and skin incisions at the medial areolar border are avoided.     

Nipple-areola reconstruction: satisfaction and clinical determinants

After performing a chart review, the authors identified 120 patients who underwent breast cancer-related reconstruction. All charts were evaluated with regard to breast mound reconstruction type, nipple-areola reconstruction type, the interval between breast mound and nipple-areola reconstruction, the number of procedures needed to achieve nipple-areola reconstruction, patient history of radiation therapy, and complications. A questionnaire was then developed and mailed to all of the patients who underwent both breast mound and nipple/areola reconstruction (n = 105) to evaluate their level of satisfaction. Of the 43 patients who returned the questionnaire, 41 completed all portions correctly. The questionnaire evaluated patient satisfaction with breast mound reconstruction; patient satisfaction with nipple-areola reconstruction; what the patient disliked most about the nipple-areola reconstruction; and whether or not the patient would choose to have breast reconstruction again. Several parameters were then tested statistically against the reported patient satisfaction.A review of all patients who underwent breast reconstruction revealed that their breast mound reconstructions were done using either a TRAM flap (59 percent), a latissimus dorsi flap and an implant (19 percent), an expander followed by an implant (9 percent), an implant only (4 percent), or other means (9 percent). The nipple-areola was reconstructed in these patients with either a star flap (36 percent), nipple sharing (10 percent), a keyhole flap (9 percent), a skate flap (9 percent), an S-flap (8 percent), a full-thickness skin graft (6 percent), or by another means (22 percent). The number of procedures needed to achieve nipple-areola reconstruction was either one (in 66 percent of the patients), two (in 32 percent of the patients), or three or more (2 percent of the patients). Eleven percent of the patients experienced the complication of nipple necrosis.Satisfaction with breast mound reconstruction was reported by 81 percent of patients to be excellent/good, by 14 percent of patients to be fair, and by 5 percent of patients to be poor. Reported satisfaction with nipple-areola reconstruction was excellent/good for 64 percent of patients, fair for 22 percent of patients, and poor for 14 percent of patients. The factors patients disliked most about their nipple-areola reconstruction were, in descending order, lack of projection, color match, shape, size, texture, and position. Statistical analysis of the data revealed inferior patient satisfaction when there was a longer interval between breast mound and nipple areola reconstruction (p = 0.003). No significant difference was observed in nipple/areola reconstruction satisfaction ratings when compared with breast mound reconstruction type (p = 0.46), nipple-areola reconstruction type (p = 0.98), and history of radiation therapy (p = 0.23). There was also no significant difference when breast mound reconstruction was compared with technique (p = 0.51) and history of radiation therapy (p = 0.079). Overall, there was a greater satisfaction with breast mound reconstruction than with nipple-areola reconstruction (p = 0.0001).     

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.     

Complete one-stage,immediate breast reconstruction with prosthetic material in patients with large or ptotic breasts

Immediate prosthetic breast reconstruction is a relatively simple, quick procedure with no donor site morbidity. This report discusses immediate one-stage breast reconstruction using prostheses in 18 patients (19 breasts) who also required a contralateral reduction or mastopexy. In all cases, an inverted-T pattern was applied to both breasts. The mean age of the patients was 49 years (range, 32 to 62 years), and the mean size of the gel implant used was 330 ml (range, 120 to 550 ml); the implant was inserted in a total submuscular pocket in seven patients and subcutaneously in 11 patients. In two patients with multiple risk factors, the prosthesis extruded, and one patient required removal for a periprosthetic infection. In 10 patients with early stage disease (T1 or T2) with tumors more than 5 cm from the nipple-areola complex, the original areola (n = 3) or nipple-areola complex (n = 7) was retained as a full-thickness skin graft.The breast shape after submuscular prosthesis insertion is different than that of the contralateral breast after a mastopexy or reduction, and nipple-areola complex symmetry was difficult to obtain; thus, this technique was abandoned in favor of the subcutaneous position (using a modified Wise keyhole pattern with a de-epithelialized portion, which still allows two-layer closure).In the subgroup of patients with large breasts or marked ptosis, a single-stage breast reconstruction procedure can be performed with symmetrical incisions. The subcutaneous position allows for symmetrical shape and nipple-areola complex symmetry to be obtained. When the tumors are small and situated in the periphery of the breast, the nipple-areola complex may be retained as a full-thickness graft.     

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.     

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.     

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。     

Refinement of the central pedicle breast reduction by application of the ligamentous suspension

In a previous article, the location of the neurovascular structures inside the breast were exactly determined using a suspension apparatus, and how to access these structures was described. The horizontal septum originates at the level of the fifth rib and curves upward into vertically oriented medial and lateral ligaments, thereby guiding the main vessels and nerves to the nipple and areola. This topographical definition is relevant to increase the precision of resection in breast reductions. In further anatomic dissections of 20 female breasts, it was found that the horizontal septum constantly divides the breast into regular sections and, consequently, it can be used as a guide to achieve symmetry in breast reductions with a central pedicle. Using it provides a more predictable and reliable method of maintaining sensation and viability within the nipple-areola complex and attaining symmetry in both breasts. Because no dermal pedicle is necessary, the size of the resulting scar can be reduced. The suspending function of the ligaments provides improved ability to shape the breast. Using this understanding of the ligamentous suspension of the breast, it has been possible to perform safe breast resections with a central pedicle, irrespective of the amount of resection and risk factors. This new approach has been used on 42 patients.     

A direct surgical approach to correct the inverted nipple

Inverted nipples are cosmetically unpleasing to the patient and can become inflamed due to mechanical difficulty with cleaning the nipple-areola complex. A surgical technique for the permanent repair of inverted nipples is described. The rationale for the surgical approach is that the major pathophysiologic basis for nipple inversion is shortened lactiferous ducts. Briefly outlined, under local anesthesia, the nipple is everted with a skin hook and held in gentle traction while a small incision is made on each side at the nipple-areola junction. Breast ducts are then divided by sharp dissection, and a drain is inserted through the tunnel under the nipple. The drain is removed in 7 to 10 days. The patient must be informed before the procedure that breast-feeding will not be possible afterward because breast ducts will be permanently divided. Advantages to the procedure are (1) no scars on the areola, (2) no stricture from sutures, (3) adequate blood and nerve supply to the nipple, and (4) decreased risk of hematoma.     

Subcutaneous mastectomy. The excess skin problem.

Subcantaneous mastectomy through a lateral approach, with preservation of the nipple and areola on a dermal pedicle, removing the excess skin at the time of aubautaneous mastectomy, is a safe procedure which results in esthetically acceptable breasts. The surgical approach greatly facilitates the removal of the entire glandular portion of the breast. The need for a second surgical procedure is eliminated. Lateral biopsy scars can be reinforced by the dermal sling support, thereby decreasing the chances of exposure of the implant. The implant is also successfully and easily held in position by the use of the dermal-fat sling support. The nipple and areola survive quite well on the dermal pedicle, with preservation of contractility and sensation, as well as of blood supply.