Short scar breast reduction

Introduction

There have been many descriptions of various short scar approaches to breast reduction. They all have different advantages and disadvantages. This chapter will briefly review the various techniques, but we will concentrate on the superomedial pedicle vertical approach ( Fig. 8.1 ) because we have found it to be the best way for us to achieve good, consistent and predictable results in the majority of patients.

Each surgeon who has developed a specific technique of breast reduction has adapted their technique based on what has been previously described. All of us try to work out what is best for our practice and we all learn from those who go before us. We should all continue to learn and adapt by continually analyzing our results and being curious about what works and what does not work. There are numerous surgeons and methods that deserve credit, but here is a basic outline:

• 1.

  Liposuction-only breast reduction : this, of course, is the ultimate short scar breast reduction and it is most effective in patients who have fatty breasts and who start off with excellent shape and good nipple position ( Fig. 8.2 ).

  

• 2.

  Parenchymal resection-only with inframammary scar: this method is only rarely used because there are only rare indications. It was originally described by Niamh Corduff and Ian Taylor and it involves removing a ring of breast parenchyma from the posterior aspect of the breast through an inframammary incision ( Fig. 8.3 ). The patient must have an excellent breast shape with good nipple position and she must have good skin elasticity.

  

• 3.

  Circumareolar approach: this technique is only applicable when the nipple and areolar complex does not need to be moved very far. It is important to realize that Louis Benelli tried to also correct the glandular ptosis by suturing it up using a lacing technique. Consistent results in correction of glandular ptosis are difficult to achieve with the purely circumareolar technique.

• 4.

  Vertical approach with superior pedicle: both Claude Lassus and Madeleine Lejour followed Georges Arié’s procedure by leaving the pedicle attached superiorly and removing inferior breast tissue. There were differences among all the techniques and so much depended upon the individual surgeon’s expertise. Daniel Marchac used a similar approach but quickly added a short, inverted T. Madeleine Lejour sutured the superior pedicle up to pectoralis fascia and then added extensive liposuction, which helped make the pedicle more pliable. She gathered or cinched up the vertical incision to try to shorten it but this resulted in more wound-healing problems and an odd shape that required time to settle as the vertical incision stretched back out.

• 5.

  Circumvertical approach with inferior pedicle: Dennis Hammond kept the inferior pedicle and took up vertical excess around the areola. ⁹ He developed a wagon-wheel permanent suture to help prevent stretching of the areola to fit the enlarged skin opening. He also adapted the vertical incision so that it curved out laterally to take up more skin excess.

• 6.

  Superomedial pedicle, vertical approach: this method is becoming more popular because it can be used as a purely vertical, short scar procedure but it can also be easily adapted to include an inverted-T skin resection (no longer short scar, of course) when the breast is very large or has poor quality skin elasticity ^.

The superomedial pedicle vertical breast reduction technique is less about scarring than it is about concepts. Most original inverted-T type approaches remove a horizontal ellipse of skin and breast tissue which, when closed, leave a medial and a lateral dog-ear. Most vertical type approaches remove an inferior vertical ellipse of skin and breast tissue which, when closed, leave a superior and an inferior dog-ear. The removal of an inferior vertical wedge of breast tissue allows the surgeon to narrow and cone the breast, thus improving its shape. It also removes the heavy inferior breast tissue and leaves behind the superior breast tissue, thereby resisting the negative effects of gravity.

Breast reduction using the (true) superomedial pedicle can provide consistent, predictable and long-lasting results with a good breast shape. The following principles are important to achieve the type of results shown in Fig. 8.1 .

Breast reduction principles

The senior author’s breast reduction results have improved significantly since the first article was published in 1999. Initially it seemed that it was all about the vertical scars. It is not. Although adding an inverted-T skin resection pattern is not needed as often as surgeons think, there are times when it is necessary. An inverted-T scar will give better results when there is too much skin especially when it is of poor quality.

The scars are the least important point. As surgeons, we should think about what we leave behind. That will tell us what we need to remove. The main points are outlined below, and they will be illustrated step-by-step in this chapter.

• 1.

  Footprint: some patients are “high-breasted” and some are “low-breasted”. The upper breast border of the footprint can only be changed with the addition of volume (implant or, to a lesser extent, fat) ( Fig. 8.1 ). Pushing parenchyma up does not last, and suturing breast parenchyma to the chest wall does not last. The lower breast border (inframammary fold [IMF]) will rise and can be elevated significantly if patients find that the brassiere band sits too low on the chest wall.

• 2.

  Skin brassiere versus breast reshaping: the best, consistent and long-lasting results are when the parenchyma is reshaped, allowing the skin to redrape. Many patients will have good skin quality and can achieve excellent results, but those patients who have lost skin elasticity (most mastopexy patients) will lose shape quickly if the skin is used as a brassiere. This is why short-term results should only be used to illustrate techniques and not to prove their effectiveness.

• 3.

  Respect gravity: removing the inferior gland and reshaping the breast parenchyma will allow surgeons to just redrape the skin without tension. By leaving the desired upper parenchyma attached to the skin flaps, gravity has less of a chance to cause recurrent ptosis. The breast is only loosely attached to the chest wall and it is held in place by skin-fascial fibers at the IMF and over the sternum.

  Removal of breast fat by liposuction-only relies on removing weight and allowing the skin to retract ( Fig. 8.2 ). Removal of breast parenchyma posteriorly can also be performed without skin removal ( Fig. 8.3 ). Neither of these procedures would be as effective with poor quality skin but the principle of removing weight shows that it is less about the skin brassiere than it is about the parenchymal reduction.

• 4.

  Remove the excess where it is: inferior and lateral. Removing the inferior vertical wedge of breast tissue will remove the undesired lower pole excess. In most breast hypertrophy patients, however, there is considerable lateral excess as well. Trying to rely on tension to pull the lateral fullness inward does not work. It is best to remove all excess parenchyma from under the lateral flap. There may still be excess tissue that needs to be removed superolaterally or inferomedially. When a patient has significant projection, some parenchyma will need to be removed from under the pedicle. Fig. 8.1 shows how the excess breast tissue was removed – inferiorly, laterally, and centrally.

• 5.

  Robert Wise’s pattern is excellent for the parenchyma . The Wise pattern (not just the keyhole opening) is an excellent pattern for the surgeon to keep in mind as to what tissue to leave behind ( Fig. 8.4 ). It is more important for the parenchymal resection than the skin pattern.

  

  Originally Robert Wise took a brassiere apart and designed a pattern that was used for the inverted-T skin resection pattern. When an inferior pedicle breast reduction is being performed, the skin is being used as a brassiere to hold up the breast shape. When a horizontal skin excision is necessary when using a superomedial pedicle, the pattern is used just for the redundant skin resection and not as a brassiere.

• 6.

  Let the skin loosely redrape over the reshaped parenchyma: Wound-healing problems result when closure is under tension. When the skin is not being used as a brassiere, the skin can be closed loosely as it is redraped over the shaped breast. We have found that using Monocryl with triclosan (an antibacterial, not an antibiotic) helps to avoid suture spitting and wound-healing problems.

• 7.

  A medial pedicle is not a true superomedial pedicle . The medial pedicle has only one axial vessel but a true superomedial pedicle has a base that extends lateral to the breast meridian. This then includes the descending artery from the second interspace as well as the artery from the third interspace, therefore, a true superomedial pedicle has a dual axial blood supply.

• 8.

  The blood supply to the breast is mainly superficial . Only an inferior pedicle and a central pedicle have a significant chest wall-based blood supply, provided by the perforating artery and vein at the fourth interspace. The rest of the blood supply is superficial. The arteries (mainly from the internal thoracic system) travel in the subcutaneous tissue and the veins can be seen separately just under the dermis draining mainly superomedially.

• 9.

  Tension is the enemy . Repairs under tension tend to fall apart. Skin closure under tension leads to wound-healing problems. Parenchyma closed under tension tends to lose its shape over time.

Superomedial pedicle vertical breast reduction

There are numerous vertical approaches and numerous pedicle choices. We prefer the (true) superomedial pedicle because it has a dual axial blood supply, it rotates easily into position without kinking or compression, and it has sensation that is equivalent or better than the other pedicles available. The inferior border of the medial pedicle becomes the medial pillar so that as it rotates into position, it leaves an elegant curve to the lower pole of the breast that gives a natural, aesthetic result.

The idea that surgeons need to choose between scars and shape is not true. The superomedial pedicle vertical breast reduction not only results in reduced scars but also maintains a good, long-lasting shape. The procedure takes less time, the blood loss is less, and the recovery is faster. In our experience the complications are also significantly less frequent with vertical breast reductions than with inverted T inferior pedicle breast reductions. There are more pucker revisions (about 5%) with the vertical approach, but they are easily corrected under local anesthesia. Medial and lateral dog-ears can be more difficult to treat.

The superomedial pedicle respects gravity. It is better to remove the inferior unwanted breast tissue and leave behind the more superiorly based breast tissue attached to the upper skin flaps because it can resist the effects of gravity both in the short and long-term.

Another advantage with the concept of the superomedial pedicle and the vertical and lateral parenchymal resection is that it can be used in much larger breast reductions even when an inverted-T skin resection pattern is needed to reduce the redundant skin. Skin does not need to be removed as often as surgeons think, but some patients have far too much skin or too much skin of poor quality. The advantages of the superomedial pedicle with the inferior resection can still be preserved even when the final closure has increased scarring with a “T”, a “J” or an “L”.

Applied anatomy

The breast has an ectodermal origin at the fourth interspace and it is attached to the skin at the nipple. The breast is only very loosely “attached” to the chest wall and it is held in place by zones of adherence: skin-fascial fibers inferiorly (the IMF); medially (over the sternum); and superolaterally (at the preaxillary crease). These are not breast structures but are similar to skin-fascial fibers over the sacrum and at the gluteal fold ( Fig. 8.5 ).

The breast itself is only loosely attached to the chest wall as it slides fairly easily over the pectoralis fascia ( Video 8.1 ). There are slightly firmer attachments at the fourth interspace. Those attachments are easily swept away during a subglandular breast augmentation. When performing a subglandular or subpectoral dissection, the blood vessels can be seen to be concentrated just above the fifth rib.

The only artery (and venae comitans) that travels through the breast parenchyma to the nipple enters the breast directly from the chest wall at the fourth interspace and travels to the nipple– areolar complex ( Fig. 8.6 ). Although there are lateral branches (which are enclosed in a loose layer which is described as a breast septum by Würinger ), there are no other arteries that course through the parenchyma to the nipple. There are, of course, vessels that supply the breast parenchyma itself, but they do not course through the parenchyma to the nipple. This chest-wall based artery and vein supply an inferior (and central) pedicle as well as the inferior flap used in a mastopexy.

The blood supply to the breast is therefore mainly superficial – the arteries and veins are in the subcutaneous tissue that is pushed outward as the breast develops. The veins are just under the dermis and do not travel with the arteries (which are about a centimeter or so deep to the skin in the subcutaneous tissue). Most of the blood supply comes from the internal thoracic (internal mammary) system via the second to sixth perforators. There is some supply from the superficial branch of the lateral thoracic artery, but the thoracoacromial system provides only minimal additional blood supply (and none to the nipple–areolar complex).

The artery to a superior pedicle ( Fig. 8.7A ) comes from the second (usually) intercostal space, descending and entering the nipple area just medial to breast meridian and is about 1 cm deep to the skin – it bleeds with significant force when cut during creation of a pure medial pedicle (it can be traced with a pencil Doppler preoperatively). The artery to the medial pedicle also comes from the internal mammary system (usually from the third intercostal space) and it curves around the sternum, penetrates the pectoralis muscle and is pushed outward in the subcutaneous tissue as the breast develops.

A true superomedial pedicle ( Fig. 8.7B ) includes both arteries from the second and third interspaces. It became apparent when creating a purely medial pedicle that the strong descending artery from the second interspace was being sacrificed ( Fig. 8.8 ). Why not keep it? The true superomedial pedicle then incorporates the blood supply to both a superior and a medial pedicle, making it very safe. The only problem is that a true superomedial pedicle (the base of which then extends lateral to the breast meridian) is more difficult to inset. But when the surgeon understands that there is no blood supply to the nipple coming through the parenchyma (it is all superficial) then the surgeon can (and should) safely debulk as much deep parenchyma as needed to facilitate an easier pedicle inset.

The fifth and sixth intercostals from the internal mammary system also enter the breast just above the IMF and they add extra security to an inferior pedicle. This is typical for other zones of adherence in the body. Many of these lower vessels are cut during creation of a central pedicle.

The only other blood supply is the superficial branch of the lateral thoracic artery and it can be seen curling around the pectoralis muscle and entering the lateral aspect of the breast. It supplies a lateral pedicle, but it may enter the breast at a more inferior level than the standard lateral pedicle design.

It is interesting that the veins do not accompany the arteries except for the deep perforator – they can be seen just under the dermis and they drain mainly superomedially. That is why we no longer infiltrate the incision lines because the infiltrating needle can puncture the superficial veins, causing small subcutaneous hematomas.

Although the main innervation to the nipple may come from the lateral branch of the fourth intercostal nerve, there is no question that good innervation comes from all quadrants of the breast. It appears that all the pedicles – lateral, medial, superior, inferior, and central – have acceptable sensation. With the medial pedicle, about 85% of patients will recover normal to near-normal sensation, but that is reduced to about 76% with a lateral pedicle and only 67% with a superior pedicle . The medial and inferior pedicles appear to have similar recovery of sensation.

Most of the glandular breast tissue is concentrated deep to the nipple and areolar complex and laterally in the upper-outer quadrant. The medial aspect of the breast has some glandular tissue but a higher proportion of fat.

It is important to understand the concept of the breast footprint. Some patients are high-breasted and some are low-breasted. This is a very important fact to point out to patients to better manage their expectations. There are only minimal changes that a surgeon can make to the footprint. The upper breast border of the footprint may start quite low on the chest wall and this cannot be changed with a breast reduction. The vertical dimension of the footprint can be quite short even in large, heavy breasts. The variation in the vertical dimension can be from 3 to 15 cm. The IMF (the lower breast border) can be quite different from one breast to the other in the same patient. The horizontal dimensions of the footprint can also vary considerably with the medial breast border determining whether a woman has a wide or narrow breast cleavage. The lateral breast border usually extends to or just past the anterior axillary line with most patients having an ideal horizontal breast base diameter of 11–14 cm. The borders of the footprint can be expanded with the addition of an implant or fat, and they can be reduced with the removal of either parenchyma or an implant.

Indications and contraindications

The best candidates for a superomedial pedicle vertical breast reduction are young healthy patients who need a small to moderate sized breast reduction (usually up to 600 g or more) ( Algorithm 8.1 ). There is more of a learning curve for the larger reductions, but the method is still excellent; the superomedial pedicle can be used for larger breast reductions even when an inverted T is needed to reduce the skin envelope.

Algorithm 8.1

Algorithm for breast reduction candidates

Very large reductions, or reductions in massive weight loss patients, are often best performed with a superomedial pedicle because it allows the surgeon to remove the heavy inferior breast tissue. Adding a T excision to the skin is rarely needed unless the vertical incision is longer than about 10–12 cm. It has been shown that adding a horizontal skin excision does not alter the revision rate. It may, in fact, be surprising to learn that it is difficult to know where to place the horizontal scar because the IMF rises with the removal of breast weight.

A true superomedial pedicle is safe in very large breast reductions with a long suprasternal notch to nipple distance (SSN-N). The pedicle should be thinned of parenchyma to prevent compression and kinking with inset. The blood supply descends as the nipple descends. A (thinned) superomedial pedicle is shorter ( Fig. 8.9 ) and safer, than an inferior pedicle.

Another indication for this technique are those who are candidates for oncoplastic immediate reconstruction ( Fig. 8.10 ), in those where the tumor is in the portion of the parenchyma normally resected (inferior, lateral and superolateral).

Some patients who have large breasts, good nipple position, good skin elasticity, and a large proportion of fat to gland may be better candidates for liposuction-only breast reduction ( Fig. 8.2 ). Some young patients (rarely) may have such a good shape that the reduction can be performed through an inframammary incision only ( Fig. 8.3 ).

Preoperative Assessment

The key ingredient to a successful breast reduction is patient education. It is important for patients to understand the limits of what can and what cannot be achieved. We make sure that patients understand the concept of “high-” and “low”-breasted ( Fig. 8.11 ). They understand that we cannot change the breast footprint – or where the breast sits on the chest wall. It is important for us as surgeons to understand patient expectations and determine if we can achieve them or not; it is better not to operate on patients who cannot accept our limitations ( Figs. 8.12 & 8.13 ).

We find that taking photographs during the consultation and marking them for the patient is very helpful. Patients often see more in their photographs than they see in the mirror. It is very important to point out the footprint on each patient and to emphasize the differences between both breasts ( Fig. 8.14 ).

Our examination consists of assessing the breast footprint – the upper, lateral, medial and inferior breast borders and then the third dimension of how the breast sits on that footprint. Does the patient have good upper pole fullness? If so, they can achieve a better cosmetic result. If a patient has a great deal of ptosis and a poor upper pole it will be futile to try to push the excess inferior breast tissue into the upper pole because it will just drop down again.

We can visualize how long the pedicle might be and if we need to warn them about a possible free nipple graft (very rare). We will assess the skin quality and skin excess and again determine if we need to warn the patient that a “hockey stick” or inverted-T scar might need to be added to their vertical scar. It is important to decide preoperatively approximately how much tissue will need to be removed.

We also warn the patients that we often cannot make their breast as small as either of us would like. When a patient requests a much smaller breast, then an inverted-T skin resection may be needed. The photographs taken during the consultation are also useful for pointing out any asymmetries and warning the patients that symmetry is a goal but impossible to achieve. Patients are also warned that breasts will change with time, gravity, pregnancy, and weight gain and weight loss.

Preoperative planning ( Video 8.2 )

Determination of new nipple position

The new nipple position is often placed at the level of the inframammary fold but in some patients the IMF can be very misleading. What we have found is that the upper breast border (the junction of the top of the breast with the chest wall) is the most static and reliable landmark. Since the upper breast border does not change with a breast reduction, it is a good landmark to determine new nipple position. The nipple is usually best located about one-third to one-half the distance up the final breast mound. This point is usually 8–10 cm below the upper breast border in an average C cup breast. The new nipple position should be determined in relationship to the existing upper breast border and not at some arbitrary distance from the suprasternal notch ( Fig. 8.15 ).

The nipple placement does not change after surgery from where it was marked. When an implant is added, for example, the suprasternal notch to nipple distance (SSN-N) lengthens on average 2 cm. But when a breast reduction is performed, the nipple stays where it was marked. If the nipple is marked at 24 cm preoperatively, it will remain at 24 cm postoperatively – both early and late. We determine new nipple position preoperatively because we know that it will stay in the same position postoperatively in relation to the upper breast border (which will also stay in the same position postoperatively). We do not adjust the nipple position intraoperatively.

Marking the upper breast border

The upper breast border is at the junction of the chest wall and the breast. This is very clear in some patients, with a definite demarcation line, and it is blurred in other patients, where the breast slopes gently away from the chest wall. The upper breast border is at the indentation of the preaxillary fold and the breast (yellow arrows in Figs. 8.12 & 8.13 ) and it can be quite low in some very low-breasted patients. The upper breast border is often (but not always) at the level of the upper edge of the stretch marks. Patients need to understand that the breast footprint cannot be lifted on the chest wall, and if their breasts are attached at a low level, they will remain at that level. Surgeons also need to understand that pushing the breast up and suturing it to pectoralis fascia does not work in raising the footprint.

Marking the level of the IMF

This level is becoming less important in determining the new nipple position, but it is important in deciding how aggressive the surgeon can be in resecting tissue at the fold in order to elevate the fold itself. Sometimes the IMF can be at quite different levels on the same patient. The surgeon can thus be more aggressive with the resection of the lower fold.

Marking the breast meridian

The breast meridian should not be drawn through the existing nipple but at the desired level. Although it does not matter where the line starts, it is easier to draw it beginning at the clavicle and then making the mark down the breast bisecting it. The nipple looks best slightly lateral to the midline and it is therefore better to err on the side of marking the meridian slightly more lateral ( Fig. 8.16 ).

Marking the new nipple position

The new nipple can then be marked at the intersection of the vertical mark (8–10 cm from the upper breast border) and the new breast meridian (8–10 cm from the midline of the sternum). This position will often be at the level of the IMF but not always. It is important at this stage for the surgeon to stand back and visualize the result to make sure that the nipple is designed at a good level both horizontally and vertically.

The surgeon has more flexibility with nipple position in patients with a very full upper pole, but he or she should place the nipple lower in a patient who has a ski-jump type of slope to the upper half of the breast. Nipples can always be raised if a revision is needed, but they cannot be lowered. If there is significant asymmetry, the new nipple position should be placed up to 1 cm or so lower on the larger breast. Not only is the larger breast heavier, but closure of a wider vertical ellipse in the larger breast will push the nipple further up than it will on the smaller breast.

Design of the skin resection pattern

Areolar opening

The top of the areola is then marked 2 cm above the new nipple position. This accommodates most areolar diameters of 4–5 cm. The areola is then drawn so that it will close as a circle. It does not actually need to be mosque-shaped since it is probably better to take out more distance vertically than horizontally. The original Wise pattern design was 14 cm in circumference, and this matches a 4.5-cm diameter areola. A large paperclip can be used as a template because it is 16 cm in length and this matches a 5-cm diameter areola. If the areola is not a “perfect” circle at the end of the procedure, it is quite simple to make the appropriate adjustments. It is important to make sure that there is symmetry in the design from one breast to the other.

It is important to draw the medial side of the areolar opening first. It should be “ideally shaped” and symmetrical from one breast to the other. The lateral part of the breast is more mobile and it can tolerate a wider design (which is often necessary in order to completely remove all remaining areolar skin).

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