JAYANTA SAHA

Surgical reduction of breast to achieve

A.smaller size,

B.aesthetically shaped breast mound,

C.Relief of symptoms of mammary hypertrophy

A.Reduction of gynaecomastia as early as 6th

century A.D.

B.Breast amputation mammaplasty by Schaller in 19th century.

C.Dieffenbach performed lower pole reduction in 1848.

D.Reproducible breast reduction technique hails from end of 19th century.

A.Very large breast

B.Shoulder pain

C.Cervical and upper thoracic backache

D.Severe embarrassment physically or sexually

E.Recurrent intertigo

A.Inability to exercise due to breast discomfort

B.Difficulty with breathing during exercise

C.Difficulty finding clothing to fit

E.Grooving and hyperpigmentation of shoulder of shoulder strap areas

A.Early horizontal& combined scar technique:

Passat procedure

Schwarzmann medial dermoglandular pedicle

Biesenberger technique

B.Wise pattern approaches:

Inferior pedicle technique(Courtiss,Goldwin)

Superior pedicle technique(Pitanguy,Weiner)

Horizontal bipedicle(strombech)

Vertical bipedicle(Mckissock)

Lateral pedicle technique.

Superomedial pedicle technique(Orlando)

Superolateral pedicle technique(Skoog)

Central mound technique(Biesenberger)

Breast amputation & free nipple graft.

C.Short-scar technique: Lassus –Lejour technique Hall-Findlay technique Marchac short scar technique Regnault B technique L reduction Benelli round block technique Goes periarolar technique Hammond SPAIR approach D.Liposuction assisted reduction(Courtiss &

matarasso)

Depends on

breast size,

estimated resection vol.

breast shape,

experience of surgeon.

Breast hypertrophy may be divided into

A.mild(resection <200g.)

B.Moderate(<200-500g.)

C.Severe(500-1500g.)

D.Gigantic(>1500g.)

A woman with 34” chest circumference(beneath IMF & under arm) with 36” breast circumference(at nipple level) will have 34B cup bra/34D cup bra for 38” breast circumference.

Size of cup bra:

32’’-34” =100 gm.

36”-38”=200 gm.

40”-42”=300 gm.

44”-46”=400 gm.

So 40DD cup bra to 40C size needs resection of 300+300=600gm.of breast on each side.

A.Nipple lies 21cm.from sternal notch & midsternal point.

B.nipple lies 7cm. from IMF.

C.Nipple forms equilateral triangle with other nipple & sternal notch.

D.Pitanguy recommended new nipple level at midhumeral point plus 2/3 cm.

E.Average areolar diameter 38-45 cm.

A.Vertical scar technique(Lassus-Lejour,Hall-Findlay).

B.Periareolar technique(Benelli,Goes).

A.Vertical technique(Lassus-lejour,Hall-Findlay,SPAIR)

Wise-pattern technique(Inferior,centralpedicle,superomedial pedicle)

If nipple distance is within 22 cm. from IMF ,Central mound reduction may be tried.

Breast amputation & free nipple graft is meant for gigantomastia.

It includes

A.Superior pedicle

B.Inferior pyramidal glandular resection

C.Closure with vertical scar

Modification includes

A.Skin undermining adjacent to vertical parenchymal pillar edges

B.Suture suspension of the pedicle to pectoralis muscle fascia

C.Total breast liposuction

A.Midline of chest is drawn from suprasternalnotch down onto abdomen.

B.Second line is drawn from midclavicularpoint to nipple.

C. New nipple position is marked on forward projection of index finger onto anterior surface of breast.

.

D.Lateral & medial lines are drawn by pushing breast medially & laterally respectively.

E.Lower mark ,a curved line is made joining lower ends of medial& lateral lines between 4-6 cm. from IMF.

F.Superomedial pedicle is designed with 6-8cm. base & 1cm.cuff left around areola

A-B& A-C lines represent vertical closure after reduction,length is 5-8cm.,B-C =8cm.C-D,B-E have lazy s shape

A.Haematoma:<1% within 12 hrs. of surgery,unilateral,manifested by pain,swelling& bruising may lead to tension - induced ischaemia .Treatment is surgical evacuation & control of bleeding intercostal perforators.

B. seroma:1%-5%,aspiration will suffice.

C.Infection:cellulitis controlled with antibiotics & abscess formation as a sequelae of infection within undiagnosed haematoma & fat necrosis needs open drainage.

D.Skin necrosis:presents in tension related wise pattern reduction at the inverted T flap due to compromise at tip of skin flap.It is virtually absent in vertical reduction.

E.Fat necrosis:common in long central or inferior pedicle in huge breasts.It may mimic carcinoma & causes pt’s anxiety but mammography & fnac will make diagnosis.

F.Nipple loss:associated with smoking.Longpedicle or thick pedicle folded in vertical technique causes nipple loss due to inadequate vascular perfusion.

G.Nipple numbness:central pedicle preserve more sensation than upper pole pedicle.

H.Hypertrophic scars:occurs most medial & lateral ends of horizontal limbs of wise pattern technique.Reducing tension,postoperativetaping,silicon application,steroid inj. Maa be helpful.

I.Assymetry:what is removed is more important than what is left in reduction surgery.Prevention of this complication is important because reoperation may be required.

J.Inadequate or overreduction:problematic for neophyte than experienced surgeons with vertical technique.Overresection is risky for grade III ptosis with empty upper pole.

K.Boxy breast deformity:presents in inferior pedicle technique due to inadequate inferomedial or inferolateral resection.

L.Inflammatory scarring:visible on mammography(whorled appearance).

M.Recurrent enlargement:secondary to massive weight gain & ongoing virginal hypertrophy.Reduction should not be done until breast growth is static for 1yr unless symptoms are incapacitating or ulcers are imminent.

N.Inability to breast feed:breast feeding is technically possible but succesful feeding is rarely achieved.

O.Cancer & breast reduction:reduction does not cause cancer rather reduces risk due to volume depletion.

P.Inadequate mastopexy result:results from inadequate skin resection to shape the gland or breast suction.

Q.Dog ear:occurs in medially & laterally in wise pattern technique but inferiorly in vertical technique.Minor adjustment under L.A. may correct if deformity does not spontaneously resolve within 6 months of original reduction.

Reduction mammaplasty is an establised,highly successful technique reduces size of large female breast and also complications associated with it.

Satisfaction of pt. is high.

Results are predictable.

THANK YOU