Reduction mammoplasty by the central pedicle, avoiding a vertical scar

The no-vertical scar technique for oncoplastic breast reconstruction

INTRODUCTION

Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri‑areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction.

METHODS

Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation.

RESULTS

Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required.

CONCLUSION

The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

Comparison of mammography sensitivity after reduction mammoplasty targeting the glandular and fat tissue

OBJECTIVE

Mammography may have some limitations in the diagnosis and screening of breast cancer for women who have previously undergone breast reduction surgery. This study aimed to investigate how the structural defects in the breast tissue formed by postoperative changes are reflected on mammography.

MATERIAL AND METHODS

The records of patients who had previously undergone breast reduction surgery and who were requested to undergo mammography for breast cancer screening by the general surgery clinic were retrospectively studied. The patients' ages, surgical procedures, postoperative follow-up periods, amount of removed material, and histopathological and mammographic results were studied. The patients were classified into 3 groups: those older than 40 years who underwent reduction mammoplasty targeting predominantly the glandular tissue (group 1), those younger than 40 years who underwent reduction mammoplasty targeting predominantly the fat tissue (group 2), and those older than 40 years who were diagnosed with breast hypertrophy and were not operated (group 3).

RESULTS

The mean follow-up period of the patients was 6 (2-10) years. The mean value of resected tissue was 1120 g (680-2070) in group 1 and 1220 g (720-1980) in group 2. The mean age at the time of surgery was 45 (40-70) years for group 1 and 35 (24-40) years for group 2. All patients in group 1 were classified in Breast Imaging-Reporting and Data System (BI-RADS) category 1-2; 28 patients in group 2 were classified in BI-RADS 1-2, 4 were classified in BI-RADS 3, and 8 were classified in BI-RADS 0. In group 3, 35 patients were classified in BI-RADS 1-2, 4 were classified in BI-RADS 3, and 1 was classified in BI-RADS 0.

CONCLUSION

We believe that breast reduction surgery targeting predominantly the glandular tissue in patients older than 40 years increases mammographic sensitivity.

Central pedicle reduction mammoplasty: a reliable technique

Reduction mammoplasty is one of the most frequently performed procedures in plastic surgery for macromastia or gigantomastia. Recently it is also evolved for oncoplastic breast cancer surgery due to equivalent in terms of outcome for breast conserving surgery with radiotherapy versus mastectomy. Various techniques and modification has been made to achieve long lasting and aesthetically good result with minimal morbidity. Central (posterior) reduction mammoplasty is known for its versatile pedicle due to its good blood supply and innervation for maintaining of nipple sensation with unremarkably long term complication and proven in preservation of breastfeeding function. It is one of the good and reliable options to correct breast hypertrophy and ptosis. Various modifications were introduced by different authors to improve the technique and reduce scar formation which will give more satisfaction to patients.

Treatment of adolescent gynecomastia

PURPOSE

Adolescent gynecomastia is common but variable in severity. The disease may be self-limited. Although antiestrogen therapy can be used in persistent gynecomastia, results are mixed. Subcutaneous mastectomy via a circumareloar incision is familiar to most pediatric surgeons and provides excellent cosmetic results in most cases. Severe gynecomastia may require alternative procedures. There is little information in the pediatric surgical literature to provide the pediatric surgeon with treatment options for these children. A variety of techniques have been used by plastic surgeons for female patients requiring breast reduction and are sometimes a useful addition to the surgical repertoire for the management of very large breasts in adolescent gynecomastia. We reviewed our experience with the use of inferior pedicle reduction mammaplasty and subcutaneous mastectomy in adolescents with gynecomastia and describe the techniques used.

METHODS

After obtaining institutional review board approval, a retrospective review was conducted on all patients operated on for gynecomastia from January 1999 to March 2009. Data recorded included patient demographics, diagnostic evaluation, medical and surgical treatment, complications, and outcome.

RESULTS

Twenty patients underwent an operation for gynecomastia. Eight patients had bilateral inferior pedicle reduction mammaplasty, and 12 patients underwent either unilateral or bilateral subcutaneous mastectomy. The mean age at operation was 15.5 years (range, 14-18 years). In all cases, the histopathologic feature was consistent with gynecomastia. There were no postoperative wound infections. One patient developed a seroma after subcutaneous mastectomy requiring drainage. The mean amount of tissue removed after bilateral reduction mammaplasty was 275.1 g. No patients had devascularization of the nipple-areolar complex or nipple loss. One patient had mild subcutaneous asymmetry after a reduction mammaplasty that required no further intervention. Seven patients (87%) had an excellent cosmetic outcome after reduction mammaplasty. Mean length of follow-up was 18.8 months.

CONCLUSIONS

Although many adolescents with true gynecomastia have mild or self-limited disease, operative treatment may provide significant benefit to the remainder. Milder grades of gynecomastia can be managed with subcutaneous mastectomy. Selected severe cases can be safely and effectively treated with reduction mammaplasty.

Seventeen years of experience with reduction mammaplasty avoiding a vertical scar

BACKGROUND

It is important to reshape the breast with the least scar possible. This has led us to develop a technique for large breasts where the vertical scar was eliminated.

METHODS

The new nipple is positioned at 19-21 cm. The level of the new inframammary line (IML) is marked 6 cm below the new areola. All the area between the marked IML and the present sulcus is de-epithelialized. The upper flap is undermined beginning from the new IML. The tissue excision is performed medially and laterally leaving a central pedicle that also carries the nipple-areola complex (NAC). The dermoglandular pedicle is shaped conically with breast-shaping sutures. The NAC is passed under the upper apron flap through its new opening.

RESULTS

We retrospectively reviewed 145 patients who were operated on over the past 17 years. The mean age of the patients was 41 years. The mean distance preoperatively from midclavicle to nipple was 35.3 cm. The average weight of breast tissue excised was 1073 g per side. Seventeen patients (11%) suffered from minor complications.

CONCLUSION

This technique works especially well in breast reduction cases where a large mass excision is required. The horizontal scar is obvious only when the patient is lying down and cannot be seen by the patient herself. There is no risk of destroying the circular feature of the areola, which is pulled inferiorly by the vertical scar in the other techniques.

No-vertical-scar technique versus inverted T-scar technique in reduction mammoplasty: a two-center comparative study

Currently, a reverse T-shaped scar remains in the infraareolar area after most of the frequently used techniques for reduction mammoplasty. A two-center study was performed for an understanding of the effects from the amount of scars on the aesthetic satisfaction of patients. Long-term follow-up results for 24 patients who underwent the McKissock (inverted T-scar) technique (group 1) in a university hospital were compared with the results for 29 patients who underwent a "no-vertical-scar technique" (group 2) at another hospital in terms of aesthetic results. With this aim, a questionnaire was designed to assess the patients' degree of aesthetic satisfaction with different aspects. Additionally, the most current photos of each patient were evaluated for aesthetic results by four physicians and four medical students. Areola-fold and nipple-notch distances were measured as an objective evaluation. The significance of the results was tested using dependent or independent sample t tests. Notch-nipple and areola-fold distances both were greater in group 2 than in group 1, both preoperatively and postoperatively (p < 0.001). The personal satisfaction questionnaire showed that the group 2 patients rated scar satisfaction and postoperative activity levels higher (p < 0.001) than the group 1 patients (p < 0.05), but that group 1 rated nipple position higher (p < 0.05). There was no significant difference between the two groups in terms of general aesthetic satisfaction. Physicians who evaluated patient photos ranked the scars of group 2 as significantly superior to those of group 1 (p < 0.01), whereas they did not rate other features as significantly different. However students could not determine any superiority of any feature between the two groups. The no-vertical-scar technique gives the impression of a breast that has not undergone surgery because it leaves no scars in the infraareolar area and invisible scars in other areas. This situation improves the degree of satisfaction for patients in the postoperative period. When the general aesthetic success and the ratio of complications were evaluated, the no-vertical-scar technique was found to be just as successful as the T- scar technique, which is practiced widely.

Curtain type combined pedicled reduction mammoplasty with internal suspension for extensive hypertrophic and ptotic breasts

Correction of extensive hypertrophy and ptosis of the breast with a long distance between the jugular notch of the sternum and the nipple presents a number of surgical challenges: Maintaining adequate nipple-areola perfusion, preserving sensation and function, minimising scars, and forming a juvenile breast shape. The curtain type bipedicled mammoplasty with internal suspension combines the following procedures: the surface of the new breast is built entirely by a cranially based flap, thus avoiding a vertical scar and stabilising the periareolar wound. The nipple-areola is pedicled caudally as well as centrally, thus optimizing perfusion and maintaining sensation and the capacity for lactation. Fixing of deepithelialized skin stabilises the residual breast tissue at the thoracic wall and forms an internal suspension.

Plastic surgery and the teenage patient

Over the past year, the media have reported an increase in the number of teenagers undergoing plastic surgery, and with a tone of faint alarm have suggested that this merits some cultural self-scrutiny. This paper presents the statistics on the number and types of plastic surgery operations done in teenagers over the last eight years and discusses these in the context of cultural influences and societal concepts of beauty. The reason to have plastic surgery is psychological and involves body image, which is defined as the subjective perception of the body as it is seen through the mind's eye. To explain why changing the external appearance affects personality and behavior, the complex psychological reactions that occur after an operation that alters the size or shape of a body part are reviewed. Body image development occurs in stages, and puberty stands out as a particularly sensitive time as the teenager undergoes major changes in his or her physical appearance and does this at a time of heightened vulnerability to the opinion of others. Plastic surgery to correct a truly unattractive feature is enormously successful and remarkably free of conflict in this population. Teenagers undergo a rapid reorganization of their self-image after plastic surgery with subsequent positive changes in behavior and interpersonal interactions. The key to achieving success with plastic surgery is patient selection. The core value of the surgery lies not in the objective beauty of the visible result, but in the patient's opinion of and response to the change. Good patient management includes selecting candidates with clear and realistic expectations who are free of psychopathology. There must be true informed consent and attention to psychological issues must continue into the postoperative period. It is the responsibility of the patient's physician and plastic surgeon to recognize a need for psychiatric evaluation and to help the patient get this as needed. The eight operations most commonly done in the teenage population are rhinoplasty, ear surgery, reduction mammoplasty, surgery for asymmetric breasts, excision of gynecomastia, augmentation mammoplasty, chin augmentation, and suction assisted lipoplasty. Each of these is reviewed with regard to techniques, expectations, risks, and logistics. Guidelines for timing the referral of teenage patients for plastic surgery evaluation are given.