Which technique for which breast? A prospective study of different techniques of reduction mammaplasty

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1 British Journal of Plastic Surgery (1999), 52, The British Association of Plastic Surgeons Which technique for which breast? A prospective study of different techniques of reduction mammaplasty P. Giovanoli, C. Meuli-Simmen*, V. E. Meyer* and M. Frey Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical School, University of Vienna, Austria; and *Division of Hand, Plastic and Reconstructive Surgery, Department of Surgery, University Hospital Zurich, Switzerland SUMMARY. This study was designed to analyse the outcome of three different techniques of reduction mammaplasty with long-term follow-up. We developed a prospective protocol to record patient satisfaction and complaints as well as to objectively quantify the final result. The techniques used were the B-technique of Regnault, the Eren technique and the Frey technique. The technique was chosen according to a preoperatively applied protocol. Eighty-one women, all of whom exhibited physical symptoms of macromastia, were followed up postoperatively for 12 months to 5.4 years (mean 31.8 months). The relief of chronic back pain, improvement of mastodynia and overall satisfaction were rated by the patients subjectively and were reduced with all three techniques. Long-term stability of the postoperative result, especially of the vertical inframammary distance, was achieved in the techniques using a central pedicle and dermis suspension, namely the Eren and the Frey techniques. In smaller and medium-size reductions a medial submammary scar can be avoided using the Frey techniques. Complications, secondary scar and dog-ear revisions were significantly less frequent in the techniques with B-shaped skin incisions. For reductions with nipple transpositions up to 10 cm we prefer the Frey technique. In reduction mammaplasties with nipple transpositions more than 10 cm the Eren technique should be performed. The free nipple areola graft is the procedure of choice in the treatment of gigantomastia. Keywords: breast reduction, superior pedicle, central pedicle, dermis suspension, prospective study. Reduction mammaplasty is one of the more frequent procedures in plastic surgery with a large number of technical variations and modifications proposed in the literature. This study was designed to evaluate the longterm efficacy of the three different techniques used in our unit during the last 6 years. Many authors have investigated the outcome of reduction mammaplasty by addressing symptom resolution, morbidity and patient satisfaction. Only a few have focussed on objective assessment of the final result by measurements and comparison of different techniques. 1,2 In an attempt to address this, we developed a prospective protocol to record patients satisfaction and complaints as well as to objectively quantify parameters of shape of the reduced breast. The reduction technique was chosen according to a preoperatively applied protocol. The patients were treated by three different techniques: 1. Initially, for smaller and medium-size reductions, the B-technique of Regnault was used. This technique with a superior pedicle offers the advantage of preventing a medial submammary scar For larger reductions the Eren technique, which is based on a central pedicle principle and includes the advantage of dermis suspension, was performed. 4,5 3. Finally, the advantages of both techniques, i.e. prevention of a medial scar and long-term stability by dermis suspension, were combined in the Frey technique, applicable for smaller and medium-size reductions. 5 The outcome was tested by standardised check ups to evaluate the development of the long-term result. Patients and methods Since 1990, all women who underwent reduction mammaplasty for macromastia and ptosis at the University Hospital of Zurich, Switzerland were included in a prospective documentation protocol. Patients treated for gigantomastia by reduction mammaplasty with free nipple transfer were excluded from the study. A nipple transposition distance of up to 10 cm was treated by the B-technique (n = 20), or by the Frey technique (n = 30). Nipple transpositions of over 10 cm were treated by the Eren technique (n = 31). Preoperatively, each patient rated their symptoms back pain, shoulder pain, painful bra strap grooves, mastodynia from absent (0) to severe (5). Using a 6-grade scale for subjective ratings (ranging from 0 to 5) the patients were not allowed to give a median value. With regard to limitations of activity, the women were asked to describe their physical limitations (jogging, running, aerobic exercise and even walking) on a scale of 0 5, corresponding to the level of limitation. 52

2 Prospective study of different breast reduction techniques 53 Finally, the patients were asked to give a personal ranking of their appearance on a scale of 0 5. Preoperative height, weight, body mass index (BMI) and the sternal notch-to-nipple distance were recorded for each patient. In addition, we measured the vertical inframammary distance (the distance between the inferior border of the areola and the inframammary fold), the horizontal distance between the sternal midline and the nipple, the distance between the inframammary scar and inframammary fold postoperatively and, finally, the horizontal and vertical areolar diameter for objective, quantitative evaluation of the breast shape. Chest form, breast asymmetry and the presence of scars and dog-ears were documented. The shape of the breast, the degree of ptosis, the form and the shape, and the sensibility of the nipple areola complex (NAC) were subjectively ranked on a scale from 0 to 5 by the patient. Standardised photographs were taken of the breasts. The women were interviewed and examined at least 3, 6 and 12 months postoperatively, some up to 5.4 years after surgery. Statistical calculations were performed using StatView 4.5 TM on Macintosh (Abacus Concepts, Berkeley, CA, USA). Non-parametric tests, the Wilcoxon signed-rank test and the Mann Whitney U-test, were used to determine the statistical significance. Results are displayed either as bar or line charts with error bars (standard error). Figure 1 Improvement in the limitation in sporting activities (scale 0 5). Results Check ups were scheduled at 3, 6 and 12 months after the operation, and late check ups up to 5.4 years. We present a selection of results showing the preoperative state, the postoperative change and the long-term result. The mean follow-up was 28.8 months for the Regnault group, 30.3 months for the Eren group and 33.5 months for the Frey group. The average age of the patients, their height and weight and the preoperative sternal notch-to-nipple distance are listed in Table 1; the average reduction as well as the hospital stay are Figure 2 Reduction in back pain by reduction mammaplasty (scale 0 5). shown in Table 2. The mean weight decreased slightly in all three groups, but there was no significant longterm change. A significant improvement in the physical and social activity was noted in the short- and long-term follow-up for all three groups (Fig. 1). Back pain was significantly reduced in the Eren and Frey groups (Fig. 2). Table 1 Patient data 1 B-technique (Regnault) Eren technique Frey technique n = 20 n = 31 n = 30 Age [y] 23.4 (SD 4.0) 31.6 (SD 10.1) 29.4 (SD 12.0) Height [cm] (SD 6.3) (SD 7.4) (SD 7.6) Weight [kg] 61.9 (SD 7.9) 69.1 (SD 9.5) 60.1 (SD 8.9) BMI [kg/m 2 ] 22.8 (SD 2.8) 25.3 (SD 2.7) 22.3 (SD 2.8) Sternal notch nipple [cm] 26.4 (SD 3.4) 30.5 (SD 3.1) 26.4 (SD 2.6) (preoperative) Mean follow-up [months] 28.8 (SD 19.2) 30.3 (SD 12.9) 33.5 (SD 6.8) Table 2 Patient data 2 B-technique (Regnault) Eren technique Frey technique Reduced breast tissue [g/side] (SD 143.7) (SD 271.7) (SD 180.5) n = 40 n = 62 n = 60 Hospital stay [days] 6.5 (SD 0.8) 6.6 (SD 1.3) 5.8 (SD 1.3) n = 20 n = 31 n = 30

3 54 British Journal of Plastic Surgery Figure 3 Improvement in mastodynia (scale 0 5). Figure 5 Improvement in patient satisfaction with size (scale 0 5). Figure 4 Improvement in patient satisfaction with shape (scale 0 5). Figure 6 Improvement in patient satisfaction with degree of ptosis (scale 0 5). Mastodynia was significantly reduced by the reduction mammaplasty in the Eren and Frey groups. The drop in the B-technique group was statistically not significant (Fig. 3). In the long-term follow-up, there was a significant subjective improvement concerning shape and size of the breast and degree of ptosis for each of the three groups. There was no statistically significant difference between the groups (Figs 4 6). The postoperative increase of the sternal notch-tonipple distance ranged from 0.8 to 1.3 cm in the two techniques with dermis suspension, the Eren and Frey techniques, compared to an increase of cm on average for the B-technique group. The vertical inframammary distance, intraoperatively fixed to 5 cm, was in the long-term follow-up 7.1 cm (SD 1.0) for the B- technique group, 7.5 cm (SD 1.5) in the Eren group and 6.7 cm (SD 1.1) in the Frey group. The mean diameter of the areola at the time of surgery was 42 mm (range mm). Postoperative changes of horizontal and vertical diameter as a parameter of irregularity are illustrated in Figure 7. Persistent periareolar wrinkling was found in 15% of the B-technique cases, in 3.2% of the Eren cases and in 13.3% of the Frey cases in the long-term follow-up. A persistent sensory deficit of the NAC in the Figure 7 Postoperative increase of horizontal and vertical diameter of the areola. n = number of breasts. postoperative course was documented for all three techniques. The nipple sensibility (scale 0 5) decreased from 4.8 preoperatively to 3.8 one year postoperatively in the B-technique group (statistically significant), from 4.2 to 3.6 in the Eren group (P = N.S.) and from

4 Prospective study of different breast reduction techniques 55 Table 3 Complications B-technique (Regnault) Eren technique Frey technique n = 20 n = 31 n = 30 Minor complications 41.6% 65.6% 41.4% Major complications 4.7% 6.7% 3.4% Correction of dog-ears/scar 14.2% 26.6% 8.2% Figure 8 Nipple sensibility pre- and postoperatively (scale 0 5). n = number of breasts. 4.7 to 4.5 in the Frey group (P = N.S.) (Fig. 8). We critically listed all the complications including the minor ones, minimal fat necrosis, delayed wound healing or infection. The incidence was 41.6% in the B-technique cases, 65.6% in the Eren cases and 41.4% in the Frey cases. Revisions were necessary in 4.7% of the B-technique group, in 6.7% of the Eren group and in 3.4% of the Frey group. Some (14.2%) of the B- technique cases, 26.6% of the Eren cases and 8.2% of the Frey cases required secondary revisions of scars, of dog-ears and of the NAC (Table 3). Discussion Patients seeking a breast reduction are usually motivated by a desire to get rid of the physical symptoms. Many women are embarrassed by comments related to their breasts. Younger patients do not incorporate their large breasts into their body image. 6 Poor posture associated with macromastia is a symptom of the increased load on the skeletal system, but also a way to hide large breasts. Patients requiring primary correction of ptosis often seek improvement of their aesthetic appearance and are more worried about scars than patients with large breasts. The goal of this prospective study was to focus on both the subjective view and the objective assessment before and after breast reduction. We felt it important to apply the protocol preoperatively, because the shape of the breast and the quality of the tissue might influence the postoperative long-term result. We tried to analyse both aspects of breast hyperplasia, the physical symptoms as well as the aesthetic appearance of the breast, by prospective subjective ranking and objective measurements before and after reduction mammaplasty. We studied 81 women whose breasts were reduced using three different techniques: the B- technique, the Eren technique and the Frey technique. The latter was developed on the basis of unsatisfying hypertrophic medial scar formation of the Eren technique and secondary sagging of the B-technique (Figs 9, 10). Combining the B-shaped skin incision of the Regnault technique and the advantage of dermis suspension for long-term stability was the basis of this new technique (Fig. 11). The mean average breast tissue removed was similar in the B- and Frey technique groups, whereas in the Eren group nearly double the amount of the former two was resected, as expected in those patients with nipple transposition distances of more than 10 cm. Whereas most women did have an initial decrease in weight, the longterm results did not include a significant stable weight loss. The relief of the most common symptom, chronic back pain, was confirmed by Strömbeck. 7 In his study 83% of patients with back pain had improvement or relief of their symptoms following reduction mammaplasty. Berg et al reported also that 47% became painfree and 35% of the patients had improvements in more than 50% of their initial symptoms. 8 Our patients experienced considerable improvement in back pain independent of the technique of the surgical procedure. This observation is most simply explained by the decrease of breast weight 9 but may have a postural component. It is widely agreed that reduction mammaplasty significantly improves symptoms associated with macromastia. 8,10,11 The limitation in physical activity decreased significantly for all three groups in the long-term follow-up. Boschert et al reported a significant increase in exercise and other sporting and social activities in their outcome analysis of reduction mammaplasty. 12 However, Davies et al found that exercise and activity levels were not related to breast size and that the activity level of women did not increase following breast reduction. 13 Mastodynia was not improved in the B-technique group. Symptoms of breast pain were markedly reduced by the Eren and Frey techniques. Dermis suspension might lead to some pain relief by reducing the vertical tension of the remaining breast tissue. Satisfaction about shape and size of the breast was high. The reduction of volume and weight seems to be the primary goal for the patient, who might not judge the postoperative result as critically as the surgeon. 14,15 However, the subjective results of both techniques using a central pedicle and dermis suspension, the Eren and Frey techniques, were rated higher than the

5 56 British Journal of Plastic Surgery A B C D Figure 9 (A) A 26-year-old patient 24 months after reduction mammaplasty with the Regnault B-technique, frontal view. Flattening of the superior poles of the breast caused by sagging of the breast tissue. Lateral view (B) 6 months, (C) 12 months and (D) 24 months postoperatively. Visible sagging of the breast tissue behind the submammary fold and upwards projection of the nipple areola complex in the postoperative course. A B C D Figure 10 A 38-year-old patient with breast hyperplasia. (A) Preoperative sternal notch-to-nipple distance 30 cm (right side) and 28 cm (left side), frontal view. (B) Twelve months after reduction mammaplasty with the Eren technique, frontal view. Visible hypertrophic medial scar formation and oblique distortion of the nipple areola complex. (C) Preoperative lateral view. (D) Postoperative lateral view. Good stability of the vertical inframammary distance.

6 Prospective study of different breast reduction techniques 57 A B C D Figure 11 A 22-year-old patient with breast hyperplasia. (A) Preoperative sternal notch-to-nipple distance 26 cm (right side) and 27.5 cm (left side), frontal view. (B) Twenty-nine months after reduction mammaplasty with the Frey technique, frontal view. Slight oblique distortion of the nipple areola complex visible, absent medial scar. (C) Preoperative lateral view. (D) Postoperative lateral view. Good longterm stability of the shape of the breast. result in the B-technique group. A predictive model for successful operation has not been developed so far. 16 Nevertheless, reduction mammaplasty is an effective procedure and the treatment of choice for symptomatic mammary hyperplasia. 17 The sternal notch-to-nipple distance was a stable value measured in the postoperative course for all three techniques of breast reduction. Sagging of the breast is defined as an increase in length of the vertical inframammary distance and not in a change of the sternal notch-to-nipple distance. In all our cases the vertical inframammary distance was fixed to 5 cm intraoperatively. Both techniques used for smaller reductions, the B- and the Frey techniques, showed better long-term stability of the vertical inframammary distance. Berg et al place the new submammary fold less than 7 cm distant from the nipple, which is identical to less than 5 cm from the inferior border of the areola. 18 In his series he found a mean inframammary distance of 11.5 cm (range 7 14 cm) for the Lejour technique and 8.2 cm (range 5 13 cm) for the Strömbeck technique in an early follow-up 12 months postoperatively. This corresponds to a vertical inframammary distance of 9.5 cm and 6.2 cm, respectively. In another series, Pickford and Boorman reported (again for the Lejour technique) a mean length of the vertical inframammary scar of 10 cm, ranging from 7 to 13 cm. However, only one was noted to extend below the breast onto the chest wall. 1 A slight oblique distortion of the areola was found in all three groups. The asymmetry was more pronounced in patients who underwent reduction mammaplasty by the Eren technique. These women were mostly overweight and the remaining breast was larger than in the other groups. Also, the quality of the skin and its aptitude for retraction was reduced in this group. Secondary enlargement of the areola in the B- technique group was due to the fact that, in this series, in some of the earlier patients we did not use a nonabsorbable periareolar purse string suture to prevent this phenomenon. Periareolar wrinkling, particularly in the upper part of the areola, generally resolves over a period of months. Excessive puckering of the skin due to large reductions with nipple transposition distances over 10 cm should be avoided using an inverted- T skin incision (Fig. 12). Preoperative nipple sensibility was rated higher in small-breasted women undergoing reduction mammaplasty either by the B- or by the Frey technique. This difference illustrates the different chronic traction injury to the fourth, fifth and sixth intercostal nerves. 19 Preservation of sensory branches, namely of the fourth intercostal nerve, may be possible to a higher extent in techniques using a central pedicle Further advantages of the central pedicle are the vascular security of the NAC and the conservation of lactiferous ducts. 23 The overall complication rate seems to be high for all groups, because all minor wound healing problems were cited. As expected the highest complication rate was found in obese patients in the Eren group. Complications for large (up to 50%) breast reductions are reported by different authors. 1,10,18,24 Most of these complications resolved conservatively with or without administration of oral antibiotics. Major revisions had to be performed in only a few cases in all groups

7 58 British Journal of Plastic Surgery Figure 12 A 22-year-old patient with breast hyperplasia. (A) Preoperative sternal notch-to-nipple distance 32 cm, frontal view. (B) Postoperative result 16 months after reduction mammaplasty with the Frey technique, frontal view. Puckering of the skin particularly in the upper part of the areola and slight secondary widening of the areola. (3.4 to 6.7%). Secondary scar revisions of the inverted-t skin incision and corrections of dog-ears in the Eren technique were significantly more frequent than in the other two techniques with B-shaped skin incisions. As a result of this study we now use the following therapeutic strategy to treat breast hyperplasia: For reductions with nipple transposition up to 10 cm we prefer the Frey technique. It provides 1. A good long-term stability of breast shape, especially of the submammary distance. 2. Absence of a medial scar. 3. Preservation of sensibility and conservation of vascularity and lactiferous ducts by the central pedicle. 4. A low incidence of revision procedures. In reduction mammaplasties with nipple transpositions greater than 10 cm we use the Eren technique: 1. Long-term stability is achieved by dermal suspension of the breast tissue. 2. The medial scar cannot be avoided in larger reductions because its absence would result in a permanent periareolar wrinkling. 3. Nipple sensibility, lactation and vascularity are preserved by the central pedicle. References 1. Pickford MA, Boorman JG. Early experience with the Lejour vertical scar reduction mammaplasty technique. Br J Plast Surg 1993; 46: Kurtay M. Standardization in reduction mammaplasty: a comparison of techniques. Plast Reconstr Surg 1993; 92: Regnault P. Reduction mammaplasty by the B technique. Plast Reconstr Surg 1974; 53: Eren S. Personal communications, Frey M. A new technique of reduction mammaplasty: dermis suspension and elimination of medial scars. Br J Plast Surg 1999; 52: Goin MK, Goin JM, Gianini MH. The psychic consequences of a reduction mammaplasty. Plast Reconstr Surg 1977; 59: Strömbeck JO. Macromastia in women and its surgical treatment: a clinical study based on 1042 cases. Acta Chir Scand Suppl 1964; 341: Berg A, Stark B, Malec E. Reduction mammaplasty: a way helping females with neck, shoulder and back pain symptoms. Eur J Plast Surg 1994; 17: Letterman G, Schurter M. The effects of mammary hypertrophy on the skeletal system. Ann Plast Surg 1980; 5: Dabbah A, Lehman JA Jr, Parker MG, Tantri D, Wagner DS. Reduction mammaplasty: an outcome analysis. Ann Plast Surg 1995; 35: Gonzalez F, Walton RL, Shafer B, Matory WE Jr, Borah GL. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg 1993; 91: Boschert MT, Barone CM, Puckett CL. Outcome analysis of reduction mammaplasty. Plast Reconstr Surg 1996; 98: Davis GM, Ringler SL, Short K, Sherrick D, Bengtson BP. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg 1995; 96: Hughes LA, Mahoney JL. Patient satisfaction with reduction mammaplasty: an early survey. Aesth Plast Surg 1993; 17: Raispis T, Zehring RD, Downey DL. Long-term functional results after reduction mammaplasty. Ann Plast Surg 1995; 34: Miller AP, Zacher JB, Berggren RB, Falcone RE, Monk J. Breast reduction for symptomatic macromastia: can objective predictors for operative success be identified? Plast Reconstr Surg 1995; 95: Schnur PL, Schnur DP, Petty PM, Hanson TJ, Weaver AL. Reduction mammaplasty: an outcome study. Plast Reconstr Surg 1997; 100: Berg A, Palmer B, Stark B. Early experience with Lejour vertical scar reduction mammaplasty technique. Eur J Plast Surg 1995; 18: Slezak S, Dellon AL. Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty. Plast Reconstr Surg 1993; 91: Gonzalez F, Brown FE, Gold ME, Walton RL, Shafer B. Preoperative and postoperative nipple-areola sensibility in patients undergoing reduction mammaplasty. Plast Reconstr Surg 1993; 92: Sarhadi NS, Soutar DS. Nerve supply of the nipple: only from the fourth or from several intercostal nerves? A clinical experiment and an anatomical investigation. Eur J Plast Surg 1997; 20: Jaspars JJP, Posma AN, van Immerseel AAH, Gittenberger-de Groot AC. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. Br J Plast Surg 1997; 50: Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg 1986; 39: Lejour M. Invited commentary. Eur J Plast Surg 1995; 18:

8 Prospective study of different breast reduction techniques 59 The Authors Pietro Giovanoli MD, Senior Registrar, Manfred Frey MD, Professor of Plastic and Reconstructive Surgery, Director, Department of Surgery, Division of Plastic and Reconstructive Surgery, Medical School, University of Vienna, A-1090 Vienna, Austria. Correspondence to: Dr Pietro Giovanoli, Abt. f. Plastische und Wiederherstellungschirurgie, Universitätsklinik für Chirurgie, Währinger Gürtel 18 20, A-1090 Vienna, Austria. Paper received 2 February Accepted 9 September 1998, after revision. Claudia Meuli-Simmen MD, Senior Registrar, Viktor E. Meyer MD, Professor of Plastic and Reconstructive Surgery, Director, Department of Surgery, Division of Hand, Plastic and Reconstructive Surgery, Medical School, University of Zurich, CH-8091 Zurich, Switzerland.

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