Incidence of calcifications in the breast after surgical reduction and liposuction

No-Scar Breast Reduction Utilizing Power-Assisted Liposuction Mammaplasty, Loops, and Lipofilling

BACKGROUND

In continued interest to develop and refine minimally invasive procedures, recent publications reported a scarless approach in breast lifting.

OBJECTIVES

The authors sought to describe a power-assisted lipomodeling technique combined with surgical loops to achieve breast reduction and reshaping with minimal scars.

METHODS

Between 2014 and 2018, 94 patients underwent breast reduction by combined liposuction and loops. Following infiltration of the breasts, liposuction of the outer quadrants and the lower pole was achieved to reduce the breast footprint and the lateral and inferior heaviness of the breast. After multiaxial multiplanar tunnelization, 3 types of loops were taken around the breast to suspend and elevate the breast skin envelope and parenchyma. Each loop was guided through a 3-mm, 3-hole cannula passed through skin stab incisions. The first loop was designed to reduce the breast footprint and enhance the breast projection, whereas the second loop was designed to achieve breast conus remodeling. The third loop was passed circumferentially around the areola and then cephalad along the breast axis and pulled until the desired nipple-areola complex elevation was reached. Each loop was pulled to achieve the desired breast projection and shape.

RESULTS

The authors achieved breast reduction with a mean nipple elevation of 7.3 cm, and 88% of patients were satisfied with their breast shape. The total complication rate was 1%, including mild cellulitis in 1 breast, treated efficiently with oral antibiotics.

CONCLUSIONS

The proposed technique is a novel, simple, and safe alternative to achieve breast reduction and reshaping without a scar.

LEVEL OF EVIDENCE: 4

Lipofilling in Breast Oncological Surgery: A Safe Opportunity or Risk for Cancer Recurrence?

Lipofilling (LF) is a largely employed technique in reconstructive and esthetic breast surgery. Over the years, it has demonstrated to be extremely useful for treatment of soft tissue defects after demolitive or conservative breast cancer surgery and different procedures have been developed to improve the survival of transplanted fat graft. The regenerative potential of LF is attributed to the multipotent stem cells found in large quantity in adipose tissue. However, a growing body of pre-clinical evidence shows that adipocytes and adipose-derived stromal cells may have pro-tumorigenic potential. Despite no clear indication from clinical studies has demonstrated an increased risk of cancer recurrence upon LF, these observations challenge the oncologic safety of the procedure. This review aims to provide an updated overview of both the clinical and the pre-clinical indications to the suitability and safety of LF in breast oncological surgery. Cellular and molecular players in the crosstalk between adipose tissue and cancer are described, and heterogeneous contradictory results are discussed, highlighting that important issues still remain to be solved to get a clear understanding of LF safety in breast cancer patients.

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

This article is a review of fat grafting for breast reconstruction. The use of small volume fat grafting for the correction of step-off deformities, intrinsic deformities, and extrinsic deformities of the breast, and the uses of large volume fat grafting for total breast reconstruction, correction of implant complications with simultaneous implant exchange with fat, and correction of noncancer chest wall deformities is reviewed. Cancer monitoring and the risks of cancer recurrence following fat-grafting to the breast is also reviewed.

Lipofilling effects after breast cancer surgery in post-radiation patients: an analysis of results and algorithm proposal

BACKGROUND

Lipofilling or autologous fat transfer is an established technique in plastic surgery. Herein, we describe the lipofilling effects after implant-based breast reconstruction in post-radiation patients and propose an algorithm for indication of lipofilling.

METHODS

Forty patients with a history of breast cancer were included in this retrospective analysis. Patients had undergone either breast conserving therapy or mastectomy. Twenty-six patients underwent additional radiation therapy. Patients were assessed using a post-radiation skin scoring classification.

RESULTS

In total, 68 lipofilling procedures were analyzed. Scar release, skin softening, improved quality of life, and improvement of post-radiation findings are results of lipofilling with a closed filtration system. In all patients with post-surgical radiation, an improvement of tissue quality was observed. Staging revealed that lipofilling improved mean post-radiation skin scores of 2.40 ± 0.89 to 1.21 ± 0.76 (p ≤ 0.000). There was no recurrence of breast cancer in our study patients.

CONCLUSIONS

This study introduces an algorithm using lipofilling in reconstructive breast surgery and especially in post-radiation patients with low risks as well as very high acceptance in patients with various indications for this procedure. A regenerative aspect was also detectable in patients following radiation therapy and reconstruction. Lipofilling is a safe and effective procedure with a low incidence of minor complications. It is therefore a feasible method to resolve volume deficiencies and asymmetric results after oncologic breast surgery. Nevertheless, a prospective study has now been initiated focusing on the oncologic safety of lipofilling including ultrasound and radiological examinations to validate the findings of this initial study. Level of Evidence: Level IV, therapeutic study.

Autologous Fat Grafting After Breast Reconstruction in Postmastectomy Patients: Complications, Biopsy Rates, and Locoregional Cancer Recurrence Rates

BACKGROUND

Autologous fat grafting is widely used for refinements in postmastectomy breast reconstruction. However, there are few studies evaluating outcomes in this patient population. The purpose of this study was to assess outcomes of autologous fat grafting after breast reconstruction in postmastectomy patients.

METHODS

We retrospectively reviewed the records of consecutive postmastectomy patients who underwent autologous fat grafting after breast reconstruction at a university center over a 5-year period. Patients with at least 6 months of follow-up were included. Medical records were reviewed for demographics, operative details, complications, incidence of palpable masses, and/or suspicious breast imaging findings requiring biopsy, and locoregional cancer recurrence. Descriptive statistics were generated.

RESULTS

Between January 2008 and July 2013, 108 women and a total of 167 breast reconstructions underwent autologous fat grafting for revision of postmastectomy breast reconstruction. Their ages ranged from 22 to 71 years (mean, 48 years). Fat grafts were harvested, processed, and injected using the Coleman technique. The mean number of fat grafting procedures was 1.3 (range, 1-4) per breast. Follow-up ranged from 6 to 57 months (mean, 20.2 months). Fifty-three (31.7%) breasts underwent imaging after autologous fat grafting. Suspicious imaging findings requiring biopsy were discovered in 4 (2.4%) breasts, and clinically palpable lesions combined with suspicious imaging findings requiring biopsy were present in another 4 (2.4%) breasts. All 8 biopsies showed fat necrosis, scar, or oil cysts without evidence of malignancy. One (0.6%) local complication (a wound infection at the recipient site requiring oral antibiotics) after autologous fat grafting was reported. During the limited follow-up period, there were no locoregional cancer recurrences.

CONCLUSIONS

Autologous fat grafting in conjunction with breast reconstruction resulted in a biopsy rate of 4.8%, and no cases of locoregional cancer recurrence were observed. Based on these preliminary findings, autologous fat grafting appears to be a relatively safe procedure for refinement of the reconstructed breast in postmastectomy patients.

Impact of contra-lateral breast reshaping on mammographic surveillance in women undergoing breast reconstruction following mastectomy for breast cancer

BACKGROUND

The ultimate goal of breast reconstruction is to achieve symmetry with the contra-lateral breast. Contra-lateral procedures with wide parenchymal rearrangements are suspected to impair mammographic surveillance. This study aims to evaluate the impact on mammographic detection of mastopexies and breast reductions for contralateral adjustment in breast reconstruction.

PATIENTS AND METHODS

We retrospectively evaluated 105 women affected by uni-lateral breast cancer who underwent mastectomy and immediate two-stage reconstruction between 2002 and 2007. We considered three groups according to the contra-lateral reshaping technique: mastopexy or breast reduction with inferior dermoglandular flap (group 1); mastopexy or breast reduction without inferior dermoglandular flap (group 2); no contra-lateral reshaping (group 3). We assessed qualitative mammographic variations and breast density in the three groups.

RESULTS

Statistically significant differences have been found when comparing reshaped groups with non reshaped groups regarding parenchymal distortions, skin thickening and stromal edema, but these differences did not affect cancer surveillance. The surveillance mammography diagnostic accuracy in contra-lateral cancer detection was not significantly different between the three groups (p = 0.56), such as the need for MRI for equivocal findings at mammographic contra-lateral breast (p = 0.77) and the need for core-biopsies to confirm mammographic suspect of contra-lateral breast cancer (p = 0.90).

CONCLUSIONS

This study confirms previous reports regarding the safety of mastopexies and breast reductions when performed in the setting of contra-lateral breast reshaping after breast reconstruction. Mammographic accuracy, sensitivity and specificity are not affected by the glandular re-arrangement. These results provide a further validation of the safety of current reconstructive paradigms.

Magnetic resonance imaging and ultrasound evaluation after breast autologous fat grafting combined with platelet-rich plasma

BACKGROUND

Breast lipofilling is a fairly simple and safe procedure if it is performed by experienced surgeons.

METHODS

The authors evaluated the radiologic findings from 24 breasts (15 women) subjected to a lipofilling procedure (two sessions) for corrective surgery or cosmetic reasons. Mammography, ultrasound, and magnetic resonance imaging were performed before the first lipofilling session (T0) and 12 months after the last session (T12); ultrasound and magnetic resonance imaging were used 3 months after the first session (Ti) and 3 and 6 months after the last session (T3 and T6). Volumetric evaluations were also made through three-dimensional magnetic resonance imaging reconstruction.

RESULTS

Ultrasound showed oily cysts in 66.67 percent of the breasts at Ti, 70.83 percent at T3, 62.5 percent at T6, and 45.83 percent at T12, whereas magnetic resonance imaging detected oily cysts in 8.33 percent at Ti and T3 and T6 months and 4.17 percent at T12. At Ti, T3, and T6, the cytosteatonecrotic areas identified on both ultrasound and magnetic resonance imaging were unchanged (8.33 percent), whereas at T12 those cytosteatonecrotic areas were increased on ultrasound (12.5 percent) and even more on the magnetic resonance imaging scans (16.67 percent). The average resorption percentage of injected volume was 15.36 percent at T6 months and 28.23 percent at T12 months.

CONCLUSIONS

Postlipofilling breast changes can be distinguished from malignant alterations by experienced radiologists and need not interfere with early cancer diagnosis if patients are checked regularly. Moreover, magnetic resonance imaging is very useful for breast volume assessments and for detecting possible changes during longitudinal study.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

What we should know in mammography after reduction mammoplasty and mastopexy?

BACKGROUND

Reduction mammoplasty and mastopexy (breast lift surgery) are becoming increasingly common procedures. Knowledge of characteristic mammographic findings and imaging findings of breast cancer are important to interpret mammography in this population.

METHODS

Patients undergoing a mammography examination between March 2006 and March 2012 were consecutively included. Seventy mammography examinations in 39 patients after reduction mammoplasty and 22 mammography examinations in 19 patients after mastopexy were reviewed and analyzed retrospectively. We compared the frequency of each characteristic mammographic finding between reduction mammoplasty and mastopexy. We also analyzed imaging findings of breast cancer in this population.

RESULTS

The most frequent mammographic finding of the reduction mammoplasty was nipple elevation (84.3 %). Other findings included retraction of the lower breast (80 %), thickening of the skin (78.6 %), downward shifting of the glandular tissue (47.1 %), retroareolar fibrotic band (42.9 %), and areolar skin calcification or lipid cyst (35.7 %). The most frequent mammographic finding of mastopexy was thickening of the skin (72.7 %). Other mastopexy findings included elevation of nipple (68.2 %), areolar skin calcification or lipid cyst (36.4 %), retraction of lower position (31.8 %), and retroareolar fibrotic band (31.8 %). Downward shifting of glandular tissue and retraction of the lower portion have statistically lower frequency in mastopexy cases (P < 0.05). Two breast cancers were diagnosed in reduction mammoplasty cases. One was missed and one was detected but difficult to diagnose using mammography.

CONCLUSION

Although mammography alone is not sufficient for breast screening after reduction mammoplasty, it may be possible to use mammography for postoperative follow-up after mastopexy only. So, operators should recognize that after reduction mammoplasty it will be hard to detect early breast cancer.

Radiographic findings after breast augmentation by autologous fat transfer

BACKGROUND

Fat transfer to healthy breasts, that is, in women with no history of breast disease, particularly breast cancer, is becoming increasingly popular. The main issue remains whether the transfer of fat cells to the native breast hampers breast imaging. This pilot study aimed to assess the effectiveness of radiographic evaluation after breast lipomodeling and to propose objective elements for the detection of mammographic signs, and for postoperative evaluation of breast density and Breast Imaging Reporting and Data System (American College of Radiology) classification.

METHODS

The authors retrospectively reviewed the radiographic findings of patients undergoing breast lipomodeling between 2000 and 2008. A descriptive semiologic analysis was conducted. Then, the authors compared breast tissue density and Breast Imaging Reporting and Data System categorization in 20 patients with preoperative and postoperative images available for review.

RESULTS

The descriptive analysis identified 16 percent of mammograms with microcalcifications, 9 percent with macrocalcifications, 25 percent with clear well-focused images of cystic lesions, and 12 percent with tissue remodeling. The comparative study showed no statistically significant difference between breast density findings before and after fat injection, whether using the American College of Radiology classification or a personalized rating system. Similarly, no significant difference was observed using the American College of Radiology Breast Imaging Reporting and Data System categorization before and after fat grafting.

CONCLUSIONS

Radiographic follow-up of breasts treated with fat grafting is not problematic and should not be a hindrance to the procedure. However, the authors' preliminary results should be confirmed in larger series, and the radiographic follow-up of women undergoing breast lipomodeling should be standardized to ensure reproducibility and improve patient safety.

Oncologic risks of autologous fat grafting to the breast

As the frequency of fat grafting to the breast has increased, some investigators have raised the possibility that this procedure may potentially increase the risks associated with breast cancer. Their concerns included not only interference with cancer detection, but also promotion of tumor formation or recurrence mediated by mechanisms such as aromatase expression, angiogenesis, and tumor stromal cells. However, published clinical studies describing outcomes of fat grafting to the breast in more than 2000 patients have not reported any increase in new or recurrent cancers. The reason for this apparent disconnect may lie in the small sample sizes and relatively short follow-up, but it may also reside in the considerable gap between laboratory studies or theoretical considerations suggesting potential risks and the actual clinical practice. This review discusses potential risks of current and novel approaches to autologous fat grafting to the breast within the context of both the underlying science and clinical practice.

[The adipose tissue transfer in the mammary parenchyma (part I): Review of the literature on modifications of the radiological images]

The adipose tissue transfer (ATT) in the mammary parenchyma is a subject of controversy and generates passionate debates in scientific meetings. So far, many phenomena remain unexplained. Among these phenomena, changes in mammogram images generated by the grafted adipose tissue and the interactions between the grafted adipose tissue and a clinically undetectable breast cancer are the most important. We will present a series of articles with a critical analysis of the scientific literature on each of these phenomena. This first article presents the review of the literature on modifications of the radiological images after ATT. Two types of images are most common in mammograms after ATT. These are oil cysts and microcalcifications. Regarding to the presented review of literature, there is not yet sufficient evidence to prove a similarity or not between these images generated by the ATT and those from a breast malignancy. Therefore, clinically, patients must be included in a prospective clinical trial and in terms of research, the first step should be an exhaustive description of radiological images after ATT and a comparison of these images to images of malignancy. So, it's important to include these patients in prospective protocols with close and long term follow-up.

Possible future development of implants and breast augmentation

Since the introduction of the silicone gel prosthesis in 1962, breast augmentation has become one of the most frequently performed operations in plastic surgery. As we strive for perfect results, it is important to continue to gather and review data evaluating innovative techniques and devices. Now we even have more options available for breast augmentation, whether we use them in combination or alone. By combining all of the available options (acellular dermal matrix products, silicone implant, fat grafting), we have been able to create "bioengineered breasts" with high patient and surgeon satisfaction. As always in plastic surgery, our concern is with safety; as newer technology and products are introduced to us, patient education, consent, and follow-up remain important.

Understanding modern breast reduction techniques with a simplified approach

OBJECTIVE

The purpose of this study was to analyse the geometrical principles of breast reduction, to propose a classification of reduction mammaplasty techniques and to show a simplified approach based on the authors experience.

METHODS

A thorough analysis of the geometrical differences between the normal and enlarged breast was performed. As a result of this analysis, the concept of separate management of the skin and gland for breast reduction was used as a method to classify the different techniques. Some aspects of technique selection and the authors' preferences are also discussed.

RESULTS

The four geometric differences between the normal and enlarged breast are: vertical excess, broadened base, horizontal excess and a descended nipple-areola complex. All breast reduction techniques use a specific pedicle and a separate skin incision pattern, so they should be named after the scar and pedicle used. Technique selection must consider the degree of hypertrophy and ptosis, the skin and gland quality, the patient's requirements, and the surgeon's experience and preferences. Some clinical examples are provided.

CONCLUSION

The comprehension of basic breast geometry, a universal language for communication and a simple algorithm to approach the breast reduction patient are valuable tools, particularly for the surgeon who is becoming acquainted with reduction mammaplasty procedures.

[Radiological evaluation after lipomodelling for correction of breast conservative treatment sequelae]

Breast lipomodelling has been used in our unit since 2002 to correct the sequelae of conservative treatment of cancer. Morphologically, satisfactory results have been recorded and the method is likely to develop considerably. However, the technique has also been questioned because of the possible deleterious radiological impact of injecting fat into the breast. The present work investigated the radiological aspect of conserved breast reconstructed by lipomodelling in a series of 21 patients undergoing ultrasound examination, mammography and MRI, before and after the procedure. Benign-looking microcalcifications were detected on 19% of the mammographies, small (<1cm) oily cysts and complex cysts were visible on respectively 57 and 19% of ultrasound images, whereas 47% of the MRI scans indicated cytosteatonecrotic lesions. Even though multiple events could be observed, their frequency is close to that observed following other conventional breast surgery. Besides, there is clear radiological evidence of benignity. The conclusion of the study is that images obtained after lipomodelling are satisfactory and in no way suggestive of recurrence of breast cancer. Provided that radiologists and experts are aware of this pattern, there is no impact on the radiological follow-up of the patients.

Fat grafting to the breast revisited: safety and efficacy

BACKGROUND

A 1987 American Society of Plastic and Reconstructive Surgeons position paper predicted that fat grafting would compromise breast cancer detection and should therefore be prohibited. However, there is no evidence that fat grafting to breasts is less safe than any other form of breast surgery. As discussions of fat grafting to the breast are surfacing all over the world, it is time to reexamine the opinions of the 1987 American Society of Plastic and Reconstructive Surgeons position paper.

METHODS

This is a retrospective examination of 17 breast procedures performed using fat grafting from 1995 to 2000. Indications included micromastia, postaugmentation deformity, tuberous breast deformity, Poland's syndrome, and postmastectomy reconstruction deformities. The technique used was the Coleman method of fat grafting, which attempts to minimize trauma and place grafted fat in small aliquots at many levels.

RESULTS

All women had a significant improvement in their breast size and/or shape postoperatively and all had breasts that were soft and natural in appearance and feel. Postoperative mammograms identified changes one would expect after any breast procedure.

CONCLUSIONS

Given these results and reports of other plastic surgeons, free fat grafting should be considered as an alternative or adjunct to breast augmentation and reconstruction procedures. It is time to end the discrimination created by the 1987 position paper and judge fat grafting to the breast with the same caution and enthusiasm as any other useful breast procedure.

Breast Reduction Performed by Liposuction

BACKGROUND

Large breasts and their functional sequelae can be remedied via breast reduction. This procedure has undergone frequent modification to decrease complications inherent in the large flap-based procedures. Liposuction has fewer complications than traditional incisional approaches and less scarring.

OBJECTIVE

It is our hope that dermatologic and plastic surgeons reevaluate the role of liposuction breast reduction based on our results and consider it as an alternative to incisional techniques.

METHODS AND MATERIALS

Medical charts, photoimaging, and mammography were used to assess outcomes. Statistical data were calculated using the Fisher exact test (two-sided).

RESULTS

Patients reported a satisfaction rate of 93%. Nipple elevation was measured to be at a mean of 2.57 cm compared to preoperative values. Older patients (>60 years of age) were noted to have a significantly larger nipple elevation (3.16 cm vs. 1.79 cm). Changes in volume ranged between 695.57 and 712.71 mL per breast. Radiographic changes induced by liposuction were not statistically different from those found in traditional reduction techniques. Patients with a normal body mass index (BMI) were more likely to have a larger breast reduction compared via the dip test.

CONCLUSIONS

This study illustrates the efficacy of liposuction-based breast reduction for the properly selected patient.

Familial severe gigantomastia and reduction with the free nipple graft vertical mammoplasty technique: report of two cases

BACKGROUND

: Gigantomastia, characterized by massive breast enlargement during adolescence or pregnancy, is thought to be caused by an abnormal and excessive end organ response to a normal hormonal milieu. The amputation technique with the free nipple-areola graft is the mainstay for severe macromastia, but it has been criticized because it results in a flattened, nonaesthetic breast with poor projection. This report presents two sisters with unusual, excessive breast enlargement.

METHODS

: The measured distance from the sternal notch to the nipple was 50 cm for the first case and 55 cm for the second case. The free nipple graft transplantation based on the vertical mammoplasty technique was used, and an average of 4,200 g of breast tissue per breast was removed. To increase breast projection, superior dermoglandular flaps were used

RESULTS

: The follow-up period was 24 months. The patients had long-lasting, pronounced breast mound projection, and the level of satisfaction for both cases was very high.

CONCLUSION

The ideal geometric structure of the breast is rather conical, and the authors believe that reshaping the breast tissue in a vertical plane using the vertical mammoplasty technique may be more effective in the long term and may provide better projection.

Breast reduction with ultrasound-assisted lipoplasty

Ultrasound-assisted lipoplasty for reduction of fatty breasts and fixation has been found to be a safe technique with promising aesthetic results when it is applied in selected patients and performed by a surgeon with expertise with ultrasound-assisted body contouring. From 1995 to 2000, 120 patients were treated with ultrasound energy to decrease the fatty component of the breast tissue and at the same time to lift the breast mound. Each patient was evaluated preoperatively with mammograms for correct assessment of the nature and consistency of the breast tissue. Only patients with fibrofatty and fatty breast parenchyma were selected for breast reduction and fixation with ultrasound-assisted lipoplasty. Patients with suspect mammograms (calcification) and a strong family history of breast cancer were not considered. All the prescreening and the postoperative long-term mammographic evaluations were conducted by a radiologist with high competence in breast tissue resonance. Patients' age ranged from 17 to 53 years. Total aspirate ranged from 300 to 1200 ml for size, of which 65 percent was supranatant (fat) and 35 percent was infranatant (tumescence solution and blood). Patients were operated on while they were under general anesthesia; more recently, pure tumescent anesthesia was tried with success in minor cases. Breast dimensions were assessed with breast sizers (before and after the operation), and breast measurements were assessed using a classic breast drawing. Minimum follow-up of patients was 4 years. Particular care was given to evaluating long-term breast tissue appearance through mammographic studies and to looking for suspected calcifications. No evidence of a suspect mass or calcifications was found during the 4-year follow-up. The main advantages of the technique are a significant reduction in breast volume (up to three cup sizes), significant breast lift (up to 5 cm), and nearly invisible scars (1.5 cm in length at the inframammary sulcus and at the axilla).

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.