Based on patient satisfaction, breast reduction is one of the most successful operations. Breast Reduction Techniques and Outcomes: A Meta-analysis

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1 Special Topic Breast Reduction Techniques and Outcomes: A Meta-analysis Stephen P. Daane, MD a ; and W. Bradford Rockwell, MD b Background: Although sequelae such as visible scarring often are an expected result of reduction mammaplasty, successful aesthetic outcomes depend on the surgeon s thorough understanding of the available techniques. Objective: A literature review was undertaken to compare published outcome data for the five classical reduction mammaplasty techniques as described by Pitanguy, Skoog, McKissock, Goldwyn, and LeJour. Methods: Complication rates, patient satisfaction, and symptom relief are reviewed. Management of common pitfalls is discussed. Results: Reported complication rates range from 6.5% to 22% for reduction mammaplasty, whereas reported patient satisfaction rates range from 80% to 95%. Reported rates of symptom improvement range from 70% to 100%, with a dramatic improvement in psychological well-being. Conclusion: It is hoped that an understanding of the principles and caveats published by the originators of these five techniques will promote enhanced skill in performing reduction mammaplasty. Based on patient satisfaction, breast reduction is one of the most successful operations performed by plastic surgeons. It allows women greater comfort during physical activity, relieves weight-bearing pain in the neck, shoulders, and back, and may improve a woman s self-esteem. Although the exact pathophysiology of breast hypertrophy is unknown, the condition is believed to be the product of abnormal endorgan response to estrogen. More than 68,000 breast reductions are performed in the United States each year, 1 with more than 100 techniques described in the literature. A History of the Techniques Breast reductions have been performed for hundreds of years; the original procedures were breast amputations. In 1922, Thorek 2 reported on free nipple-areola grafts with reduction. This safe, rapid procedure provides an acceptable cosmetic result and has a low complication rate in older and high-risk patients, as well as in patients with very pendulous breasts or those undergoing a resection of 2000 g or more. 3 Lexer, 4 in 1912, and von Kraske, 5 in 1923, developed the first de-epithelialized nipple-areolar pedicle techniques. In 1928, Biesenberger 6 reported on the parenchymal pedicle technique, which involved wide undermining of skin flaps and resection of the lateral quadrants. From Manhattan Eye, Ear & Throat Hospital, New York University, NY a ; and the Plastic Surgery Division, University of Utah Health Sciences Center, Salt Lake City, UT. b Accepted for publication March 24, Reprint requests: W. Bradford Rockwell, MD, Plastic Surgery Division, University of Utah Medical Center, Salt Lake City, UT Copyright 1999 by The American Society for Aesthetic Plastic Surgery, Inc /99/$ /1/ A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST

2 Figure 1. The Biesenberger parenchymal pedicle technique 6 involved wide undermining of skin flaps and resection of the lateral breast quadrants. The breast was re-formed with lateral-superior rotation. Although this technique carried a high incidence of skin necrosis due to wide undermining of the flaps, it remained the most popular breast reduction method for almost 30 years. Figure 2. The Wise keyhole pattern, based on brassiere patterns from Frederick s of Hollywood, is the basic design used in most breast reduction procedures today. A wire keyhole pattern is available commercially. 79 A, Strombeck technique, B, Skoog technique, C, McKissock technique, D, Pitanguy technique, and E, inferior pedicle technique. The breast was re-formed with lateral-superior rotation (Figure 1). Although the Biesenberger technique resulted in a high incidence of skin and nipple necrosis, it remained the most popular breast reduction method for almost 30 years. In 1956, Wise 7 ushered in the modern era of breast reduction by creating the keyhole pattern and emphasized the importance of preoperative marking. He used brassiere patterns from Frederick s of Hollywood to develop his incisions. The Wise keyhole pattern is the basic design used in most breast reduction procedures today (Figure 2). McKissock 8 reported the vertical bipedicle dermoglandular technique in 1972, which until recently was the most frequently performed breast reduction procedure in the Figure 3. McKissock technique. The vertical bipedicle technique is commonly used because of a low rate of nipple necrosis and reproducibly good results. McKissock 8,80 believed that use of the narrowest angle possible between the limbs of the Wise keyhole pattern and the addition of the lazy-s closure helped to avoid the boxy breast. These maneuvers constrict the skin envelope of the breast medially and laterally while retaining a relative excess of skin centrally, contributing to a desired conical shape. After medial and lateral dermoglandular triangles are resected, additional tissue is resected from beneath the vertical flap, converting it to a bipedicled bucket handle. The flap is thin superiorly and thick below, with a stout inferior base maintained on the thoracic wall and inframammary dermis. The nipple is elevated to its final location by folding the flap. A vertical pedicle length of up to 50 cm has been used by McKissock. 81 Figure 4. Pitanguy technique. Glandular resection is performed in a keel-like fashion while elevating the new nipple site at point A with a Kocher clamp. The keel can be thought of as a disk of breast tissue with a triangular pyramid superimposed on top of it. Pillars of the medial and lateral breast flaps are invaginated with sutures to create a conical shape for the breast. Pitanguy continues to make use of a plaster cast after surgery. 82 United States (Figure 3). Other techniques include the horizontal dermal pedicle technique, 9 the superior/horizontal dermoglandular technique 10 (Figure 4), the superior dermal pedicle technique 11 (Figure 5), the inferior dermoglandular pedicle technique (Figure 6), and the vertical mammaplasty technique with liposuction 16 (Figure 7). Recently, surgeons have attempted variants of these techniques in search of a short-scar reduction 294 A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST 1999 Volume 19, Number 4

3 Figure 5. Skoog technique. Skoog 11 was the first to describe transposition of the nipple on a vascularized dermal pedicle without underlying glandular tissue. Skoog believed that an inferior resection diminished the possibility of future breast ptosis. The dermal pedicle flap usually measures 10 to 12 cm in length, encircling the areola by at least 1.5 cm to preserve the periareolar vascular plexus. A laterally-based flap was chosen, although the circulation of a medially-based flap is also adequate. The nipple flap is undermined to give a thickness of 0.5 to 1 cm. A small back-cut excision at the superior edge of the flap permits it to rotate superiorly without compression. Medial and lateral segments of glandular tissue are sutured to create a cone shape for the breast. mammaplasty However, the trade-off with shortscar techniques for large reductions is often a less satisfactory breast shape. For the patient with minimal hypertrophy, the periareolar reduction-mastopexy technique of Goes 25 yields an excellent aesthetic result, although the polyglactine-polyester mesh used by Dr. Goes is not available in the United States. This technique is based on the principle that the skin envelope alone does not prevent early ptosis. Indications Breasts that are out of proportion to the body habitus may have adverse effects on the musculoskeletal system. Patients are commonly seen with complaints of neck, back, and shoulder pain or arthritis, postural defects (kyphosis) from attempting to hide large breasts, and deep ridges over the shoulders from brassiere straps 26 (Table 1). Breast reduction may alleviate intertriginous rashes and ulnar paresthesias. 27 Psychological problems related to body image are believed to be considerable. Women who gain weight to hide their large breasts Figure 6. The inferior pedicle technique, which was reported on by several authors independently, was developed in an attempt to maintain nipple sensitivity and to preserve lactation after breast reduction. The inferior borders of the medial and lateral skin flaps are drawn straight so that their combined length is 1 to 2 cm longer than the inframammary incision. The base of the inferior dermal pedicle is marked 1 cm above the inframammary fold so that the final scar is not irritated by a brassiere. Five cm is most commonly chosen for the Wise keyhole pattern limbs. A 3:1 pedicle length/width ratio is recommended; the width of the inferior pedicle typically measures 8 to 10 cm, although Georgiade et al 83 emphasize the importance of leaving wider pyramidal attachments to the pectoralis major muscle. Table 1. Symptoms and results of reduction mammaplasty with Skoog s method in 149 patients * Cured or Reason for Patients Mean age improved operation (%) (y) (%) Headache Psychic reasons Hygienic reasons Indenting bra straps Cosmetic reasons Thoracic-lumbar pain Shoulder-arm pain Neck pain Mastodynia * The average reduction was 1100 g per breast. may participate in exercise programs after breast reduction, resulting in improvement of their overall health. Goldwyn 28 found no improvement in pulmonary function after reduction mammaplasty. Breast Reduction Techniques and Outcomes: A Meta-analysis A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST

4 A B A B Figure 7. Lejour technique. Vertical mammaplasty was originally developed by Dartigues 84 in 1925 for mastopexy and by Lassus 85 in 1981 for reduction. It uses an upper pedicle for the nipple-areola complex, and a central breast reduction with lower skin undermining. Vertical markings are drawn on the inferior breast after pushing the breast superomedially and superolaterally. The lower marking extends to just above the inframammary fold. The top of the periareolar dome of a mosque marking is made 2 cm superior to the chosen new nipple site (the area within the mosque is deepithelialized); the total length of the mosque markings that accommodate the new nipple is 14 to 16 cm. Liposuction is performed in 50% of breasts to make modeling of the gland easier. The skin is incised and undermined, leaving a 0.5-cm fat layer under the skin flaps lateral, medial, and inferior to the submammary fold. Dissection proceeds upward behind the breast. After the central breast is partially excised, the remaining breast tissue is elevated by posterior fixation to the chest wall. A, The nipple is transposed on its superior pedicle, and the anterior breast is plicated to create a cone, which will keep tension off of the skin. B, Vertical skin suturing gathers the breast flaps and reduces their vertical length by 6 to 7 cm while the breast seems to bulge in the superior pole. Overcorrection is believed to produce better late results 16 ; final shape is expected by 2 to 8 weeks after surgery. A significant advantage of this technique is the absence of a horizontal scar. Lejour 34 reports excellent results, although it is common for other surgeons to report poor results during the learning curve. Because insurance carriers often use the standard of 500 g of tissue removed per breast as a cutoff point to determine whether a breast reduction is reconstructive or cosmetic, surgeons should carefully document symptoms, including pain, posture, shoulder grooves, and intertrigial excoriations that would substantiate the need for a medical reduction. The origins and rationale C Figure 8. Marcus 43 classified nipple-areolar circulation into three types: A, circular (70%), in which the internal mammary artery and lateral thoracic arteries anastomose in a typical circumareolar ring to supply the nipple; B, loop (20%), in which the medial and lateral branches anastomose above and below the nipple, forming a loop; and C, radial (6%), a tenuous configuration in which a strong anastomotic vascular supply is lacking. of the arbitrary standard of 500 g of tissue per breast is unknown. On the basis of normative values, Schnur et al 29 calculated that a woman of 5 ft 3 in height and weighing 140 lb would require only 300 g removed from each breast for purely medical reasons, or 200 g removed per breast for mixed cosmetic and medical reasons. At less than 200 g per breast, the operation would be considered a purely cosmetic procedure. 29 Complication Rates Table 2 compares the complication rates for the five classical techniques. In Pitanguy s 30 series, which included 2822 cases from 1962 to 1987, the superior dermoglandular pedicle technique had an overall complication rate of 6.5%. Kinell et al 26 reported a complication rate of 17.7% in 149 of Skoog s patients up to 5 years after the superior dermal pedicle technique was performed. McKissock 31 noted an 18% incidence of partial nipple loss, dehiscence, and unsightly scarring, plus several patients with skin infection or necrosis in a series of 52 patients who underwent surgery with the vertical bipedicle technique. In a comprehensive review of the inferior pedicle dermoglandular technique, Mandrekas et al 32 noted an 11.4% incidence of complications in 371 patients, whereas Bolger et al 33 reported a 13.6% complication rate in 300 patients after reduction with an inferior pedicle 296 A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST 1999 Volume 19, Number 4

5 Table 2. Complication rates for five classical techniques * Lejour With Without Pitanguy Skoog McKissock Mandrekas Bolger suction suction (2822 (149 (52 (371 (300 (~85 (~135 patients) patients) patients) patients) patients) patients) patients) (%) (%) (%) (%) (%) (%) (%) Glandular necrosis/ 1.3 > dehiscence Cutaneous problems/ Several delayed healing Hematoma/seroma Areolar problems/ nipple necrosis Unsightly / ~58* 3.3 hypertrophic scarring Sagging / 1.3 ~50* contour revisions Altered nipple/ ~70* breast sensation Occult cancer Pulmonary embolus 0.4 Total reported by author (11.2% of breasts) *There was standardization in reporting or adjustment for the amount of tissue resected. (Note: frequently the complication rates reported by the authors do not equal the totals reported in their published articles). glandular-only technique. Interestingly, in the latter study there were no problems with nipple vascularity in spite of division of the inferior dermal bridge. Lejour 34 reported complications in 11.2% of 417 breasts (a 21.2% complication rate in 220 patients) with the vertical mammaplasty technique. Hematoma Strombeck 35 reported hematoma in 2.7% of 671 patients; McKissock 36 reported hematoma in 2.2% of 360 patients; Kinell et al 26 reported hematoma in 2.5% of 149 of Skoog s patients; Lejour 34 reported hematoma or seroma in more than 10% of 220 patients; and Mandrekas et al 32 reported a 0.3% incidence of hematoma in 371 patients undergoing reduction with the inferior pedicle technique with suction drains. Drains are usually recommended during the first 24 hours after surgery to prevent hematoma. Preoperative infiltration of dilute epinephrine has been shown to reduce blood loss by 50% when compared with the noninfiltrated side. 37 Infection Because breast ducts harbor bacteria (Staphlococcus aureus and Propionibacterium acnes), breast reductions are subject to infection at a higher rate than other clean surgical procedures. In a series of 406 patients who underwent reduction mammaplasty by the inferior pedicle or Strombeck techniques, infection requiring antibiotics occurred in 12%. 38 Perioperative antibiotics are routinely used; a study of antibiotic use in 2587 surgical procedures of the breast found that 38% of predicted infections were prevented. 39 Nipple or T Junction Necrosis Maliniac s 40 dissection and x-ray injection studies elucidated contributions of the internal mammary, lateral thoracic, and intercostal arteries to the breast circulation via the medial and lateral mammary arteries. Over-reliance on the de-epithelialized dermal bridge as a vascular structure in inferior pedicle reductions may lead unwary surgeons to over-resect breast parenchyma containing the more important deep perforators. 33 Cooper 41 demon- Breast Reduction Techniques and Outcomes: A Meta-analysis A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST

6 strated a rich subdermal arterial and venous plexus to the nipple-areolar complex. Aufrict 42 noted that complications arose when either the nipple-areola complex is separated from its dermal blood supply or when glandular tissue is separated from its cutaneous blood supply. Marcus 43 classified nipple-areolar circulation into the circular (70%), loop (20%), and radial (6%) types. The radial areolar circulation type is a tenuous configuration in which a strong anastomotic vascular supply is lacking (Figure 8); patients with this type of nipple-areolar circulation are possibly the ones in whom nipple necrosis developed even when the operation proceeded well technically. If the nipple-areola appears blue and engorged, sutures should be removed to rule out pedicle torsion or hematoma. If survival is questionable, the nipple may be removed and replaced as a free graft more inferiorly on the dermal pedicle. Leeches may also be considered in cases of severe venous congestion. 44 The incidence of skin dehiscence at the T junction was 4.6% in 371 inferior pedicle breast reductions, which were left to heal by secondary intention. 32 Suturing toward the midline is practiced to decrease tension centrally at the T. Fat Necrosis Fat necrosis is more common in larger resections. Strombeck 35 reported a 16% incidence of fat necrosis in obese patients having resections of more than 1000 g. However, the incidence of fat necrosis has been reported as low as 0.8% in 371 patients undergoing an average resection of 870 g per breast. 32 Debridement with saline solution soaked wet to dry dressing changes are the timehonored treatment. Firm nodules may require excision because they may mimic malignancy. Asymmetry and the Boxy and Flat Breast Asymmetry may develop up to several years after reduction; unfavorable results in terms of contour and shape can only be judged after at least 18 months. Patients also should be counseled regarding the possibility of postpregnancy ptosis. Bottoming out may occur as a result of stretching of the skin beneath the breast, leaving the nipple-areola complex too high, thus requiring inferior skin resection or a prosthesis. The boxy breast may result from tight midline closure with relative over-resection of the central breast mass. Horizontal incisions with a lazy-s pattern are designed to constrict the skin envelope of the breast medially and laterally, while retaining a relative excess of skin centrally and thereby contributing to a desired conical shape. 31 Tacking sutures to suspend the inferior pedicle to the chest wall (or choosing a superior pedicle reduction) may prevent the flat breast. 45 Breast projection may also be enhanced by widening the angle of the limbs of the Wise pattern to greater than 90 degrees. 46 Dog-Ears Dog-ears resulting from mismatch in the length of the submammary incision and the medial/lateral breast flaps can be avoided by triangulating the Wise pattern markings with a 2-0 silk suture to check for symmetry at the beginning of the procedure (ie, E B + C D should equal E D in Figure 4). Chasing a dog-ear laterally onto the chest wall can be avoided by excising redundant skin tissue as tension is exerted medially toward the T junction. Because hypertrophic breasts in obese patients extend into the axilla without a well-defined anterior axillary fold, liposuction and excision of subcutaneous tissue in the lateral upper quadrant with plication to the chest wall will narrow the base of the reduced breast, helping to define the anterior axillary fold and enhance breast projection. Occult Cancer Malignant tumors have been found in up to 1.5% of breast reduction specimens in reported series, 47 whereas lobular carcinoma in situ has been found in up to 8% of breast reduction specimens in patients more than 40 years of age. 48 Carcinomas discovered after breast tissue is examined by the pathologist cannot be assayed for hormonal binding status because fresh, unfixed tissue is required. 49 Therefore a careful breast examination and preoperative mammography are recommended for patients 35 years and older and in patients with firstdegree relatives with breast cancer. If carcinoma is found, an oncologic consultation is necessary because the patient may require mastectomy. Caution should be exercised when performing liposuction on a gland highly prone to cancer, because it is extremely difficult to microscopically examine the liposuction aspirate. The exact effect of reduction mammaplasty on the incidence of breast cancer is unknown. A follow-up study of 1700 patients who underwent prophylactic mastectomy showed a lowerthan-expected incidence of breast cancer, 50 whereas a recent follow-up on 27,000 patients who underwent breast reduction in the Canadian health care system showed a lower incidence of breast cancer than that in cohorts. 51 Mammographic changes after reduction mammaplasty are predictable; coarse calcifications tend to develop in the second or third year in the periareolar and inferior portions of the breast along suture lines. 298 A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST 1999 Volume 19, Number 4

7 The first postoperative mammogram should be performed 3 to 6 months after surgery as a baseline for future comparison. The American Cancer Society and American College of Radiology guidelines then recommend mammography every 2 years from age 40 to 49 and yearly thereafter. Nipple-Areolar Inversion Skoog believed that a protuberant nipple could be created by transection of the lactiferous ducts, thereby eliminating traction on the nipple. The frequency of nipple invagination was 6% with Skoog s technique, compared to 18% with Strombeck s horizontal bipedicle technique. 52 Nipple projection can be increased by supporting the nipple on a dermal shelf peripherally. It is sometimes necessary to reoperate for release of a scar band or lactiferous duct causing retraction. A teardrop or comma nipple seen at the conclusion of an operation represents a mismatch between the breast parenchyma and skin envelope. It can be corrected by use of the cookie cutter pattern to resect more periareolar skin medially and laterally. Mondor s Disease Mondor s disease is a benign, self-limiting superficial thrombophlebitis of chest wall veins that can occur 3 to 7 weeks after breast reduction. No treatment is indicated. Occasionally, a surgical incision may be required to remove a thrombosed vein for pain or for cosmesis. Hypertrophic Scarring Hypertrophic scarring occurs most frequently at the medial and lateral aspects of the inframammary incision and at the circumareolar incision. Hypertrophic scars were reported in 3.3% of 371 patients undergoing reduction with the inferior pedicle technique. 32 Steroid injections (triamcinolone every 4 to 6 weeks times 3) and Silastic (Dow Corning, Midland, Mich) sheeting are helpful; scar revision may be attempted at 1 year after surgery. The inframammary incision is usually marked slightly higher than anticipated, particularly medially and laterally to coincide with the expected new course of the inframammary fold and thus hide the scar; this marking is most easily performed with the patient s arms elevated. Hypertrophic suture marks in the circumareolar incision are preventable by placing everting mattress sutures intradermally (rather than cutaneously) on the skin side of the incision. 11 Nipple Too High The ideal position of the nipple was deduced in 1955 by Penn 53 from 150 healthy adult women, 20 of whom had aesthetically perfect breasts. Penn noted that the suprasternal notch and nipples form an equilateral triangle, with limbs 21 cm in length. The average nipple-toinframammary fold length in these patients was 6.9 cm, whereas the ideal areolar diameters were measured from 38 to 45 mm. In performing a breast reduction, placement of the nipple at the level of the inframammary fold is usually performed to create a breast corresponding to Regnault s grade 1 ptosis. 54 Taking the average of 10 published series, 5 cm has generally been chosen as the ideal distance for the limbs of the Wise pattern from the areola to the submammary fold. 55 In the standing patient, the axes of the projecting nipples form a 30 to 45 angle anterior to the midline 56 ; thus preoperative markings with the patient in a recumbent position may result in the headlight deformity, in which the axes of the projecting nipples are parallel to each other. The breast should be supported with one hand as the new nipple position is marked so that rebound skin retraction after reduction does not bring the nipple higher. Moving the nipple/areola to a lower position by excising it always leaves an undesirable scar on the upper breast. In addition, correcting a high nipple requires shortening the areola-to-inframammary fold distance. A prosthesis behind the breast may be required for projection beneath the nipple. 57 In a study by Reus and Mathes, patients undergoing inferior pedicle breast reduction were monitored for 4.7 years. There was a gradual increase in distance from the inframammary fold to the areola, whereas the clavicle-to-nipple distance did not lengthen. Breast Too Small Careful planning will prevent a resection that is too large. Women s brassiere sizes are calculated by subtracting the chest girth measured under the arms from the breast girth measured across the nipples. If the breast girth exceeds the chest girth by 1 in, the cup size is an A; if the difference is 2 or 3 in, the cup size is B or C. According to Regnault, 59 a general method for calculating the amount of tissue to resect is 100 g per cup size for a 32- to 34-in chest; 200 g per cup size for a 36- to 38-in chest; and 300 g per cup size for a 40- to 42-in chest. Inability to Lactate Because the lactiferous ducts may be transected to create cutaneous nipple flaps, the possibility of re-establishing the lactatory system would seem slight. Strombeck 35 reported a 50% to 70% chance of nursing in patients who had breast reduction by nipple transposition tech- Breast Reduction Techniques and Outcomes: A Meta-analysis A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST

8 Table 3. Reasons for litigation among 50 US patients undergoing breast reduction Reason Patients Scars 43 Asymmetry 11 Nipple loss Complete 2 Partial 6 Nipple sensation 3 Nipples too high 6 Size Too small 2 Too large 3 Inverted nipples 2 niques, although in a follow-up study of Strombeck s patients, Muller 60 reported that of 10 patients who became pregnant, none were able to lactate. Lactation (expressing milk) is different than breast feeding, which is defined as an infant s ability to express adequate amounts of milk for nourishment, without supplements, for at least the first 2 months of life. Sandsmark 61 reported that in 49 patients who underwent breast reduction and who gave birth, 32 could nurse, but milk production was in no case sufficient for complete infant feeding. In the event of pregnancy after breast reduction, lactation may need to be suppressed with stilbestrol to avoid the development of cysts. Recurrent Hypertrophy Recurrent hypertrophy is extremely rare. If it occurs, it is more common in very young patients (12 to 14 years) with gigantomastia who require surgery for psychologically or socially compelling reasons. Impaired Sensation The nipple s sensibility is derived primarily from the lateral cutaneous branch of the fourth intercostal nerve. 62 Nerve branches tend to stay close to the deep fascia on the anterior surface of the pectoralis major muscle, passing at first through the deepest part of the subcutaneous tissue and then into the base of the breast. 63,64 Common practice is to dissect above this layer to preserve the nerve during inferior pedicle reduction. However, the intercostal nerve may not be the only nerve supply to the areola, because sensitivity has been reported to return with virtually any technique. A review of 170 of Lejour s patients undergoing vertical reduction revealed only 1 patient with absent sensitivity and 6 patients with reduced sensitivity after 6 months. 65 Preoperative breast volume and large resections are strongly correlated with loss of sensitivity. Slezak and Dellon 66 noted lower sensory thresholds in the nipple-areola complex of women with gigantomastia (D-cup or greater) compared with the same parameters in small-breasted women. McKissock 36 reported that at 2 years after surgery in 362 patients who had undergone breast reduction, 70% had reduced sensation objectively, 22% had normal sensation, and 8% had no sensation. Courtiss and Goldwyn 62 noted that at 2 years, objective decreased nipple sensation occurred in 35% of patients; however, the women reported a higher degree of sensibility in their breasts. Most breast reductions result in some loss of nipple sensation that will return within 2 years; it is important for the surgeon to document whether nipple sensation is intact and to discuss the possibility of diminished sensation with the patient. Patient Dissatisfaction Older patients are generally happier with the results of breast reduction than younger patients and will generally accept complications more readily. 35 In published series, patient satisfaction rates range from 80% to 95%, and symptom relief is reported from 70% to 100%. 26,67-72 Kinell et al 26 reported a 95% satisfaction rate and relief from preoperative symptoms ranging from 83% to 100% in 149 of Skoog s patients monitored for 5 years (Table 1). Gonzalez et al 71 reported that in 33 patients with an average reduction of 753 g per breast, symptoms were eliminated or improved in 81% to 100% of patients. Raispis et al 72 reported an improved self-image in 88% of 177 patients. Seventy-nine percent of these patients had preoperative neck and back pain, compared with only 26% after surgery. Severe neck pain was relieved in 81% of patients, and severe back pain was relieved in 78% of patients. Davis 69 noted marked resolution of preoperative complaints of shoulder grooving, neck pain, and back pain in 406 patients monitored for 4.7 years. Self-esteem was improved in 88%, and the overall satisfaction rate was 87%; 93% reported that they would undergo surgery again. Shoulder, neck, and back pain were eliminated in 80% to 93% of patients. In a comparison of 172 patients operated on with 6 different techniques, more than 95% of preoperative complaints were alleviated in all groups of patients. 70 In spite of these favorable reports, in a 20-year review of the malpractice experience of plastic surgeons by a major US malpractice insurance carrier, breast reduction ranked second only to 300 A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST 1999 Volume 19, Number 4

9 breast augmentation (and ahead of rhinoplasty, face lift, and lipoplasty) for procedures associated with the most severe malpractice losses. 73 Hoffman 74 analyzed the records of 50 cases of reduction mammaplasty involved in litigation and concluded that hypertrophic scars were the most frequent cause of lawsuits (Table 3). Postoperative photographs that show a range of results have been recommended as a helpful communication aid. 75 Krysander 76 reports equivalent results for breast reduction performed by those without plastic surgery training. Conclusion Breast reduction is designed to reduce the weight of the breast while improving shape and configuration. Established techniques for large reductions include operations that resect central tissue and move peripheral breast tissue to the center (Pitanguy, Skoog, Lejour), as well as operations that leave behind a central pedicle (Goldwyn, McKissock), conceptually similar to an augmentation mammaplasty. Inferior pedicle techniques are the most widely used today because they offer reproducibly good results with a low incidence of complications. However, the biggest drawback is the lack of superior pole fullness obtained with superior pedicle reductions. Although an understanding of 2 to 3 techniques allows a surgeon to handle a full range of problems, Goldwyn 77 warned that trying new procedures without fully understanding the principles and caveats is detrimental to the development of an individual surgeon s experience and skill. Reported complication rates range from 6.5% to 22%, whereas reported patient satisfaction rates range from 80% to 95%. Reported rates of symptom improvement range from 70% to 100%. In published series evaluating the psychological outcome of breast reduction, Goin and Goin 78 and Glatt 86 noted transient body image disturbances, but overall they reported a dramatic improvement in psychological well-being. References 1. American Society for Aesthetic Plastic Surgery (ASAPS) National Totals for Cosmetic Procedures. Available at: media/statistics/1998_national.html. 2. Thorek M. Possibilities in the reconstruction of the human form. Med J Rec 1922;116: Hawtof DB, Levine M, Karpetansky DI, Pieper D. Complications of reduction mammaplasty: comparison of nipple-areolar grafts and pedicle. Ann Plast Surg 1989;23: Lexer E. Hypertrophie beider mammae. Munchen Med Wochenschr 1912;59: von Kraske H. Die operation der atropischen und hypertrophischen hangebrust. Munchen Med Wochenschr 1923;60: Biesenberger H. Eine neue methode der mammaplastik. Zentralbl Chir 1928;55: Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg 1956;17: McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg 1972;49: Strombeck JO. Mammaplasty: report of a new technique based on the two pedicle procedure. Br J Plast Surg 1960;13: Pitanguy I. Une nouvelle technique de plastic mammaire. Ann Chir Plast 1962;7: Skoog T. A technique of breast reduction. Acta Chir Scand 1963;126: Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg 1975;55: Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg 1977;59: Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle technique: an alternative to free nipple grafting for severe macromastia or severe ptosis. Plast Reconstr Surg 1977;59: Georgiade NG, Serafin D, Morris T, Georgiade G. Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap. Ann Plast Surg 1979;3: Lejour M, Abboud M. Vertical mammaplasty without inframammary scar and with breast liposuction. Perspect Plast Surg 1990;4: Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a short inframammary scar. Plast Reconstr Surg 1982;69: Basile RD. Mammaplasty: large reduction with short inframammary scars. Plast Reconstr Surg 1985;76: Crow RW. Refinements of reduction mammaplasty. Plast Reconstr Surg 1983;71: Maillard GF. A Z-mammaplasty with minimal scarring. Plast Reconstr Surg 1986;77: Regnault P. Breast reduction B technique. Plast Reconstr Surg 1980;65: Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg 1980;65: Bozola AR. Breast reduction with short L scar. Plast Reconstr Surg 1990;85: Chiari Junior AC. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg 1992;90: Goes JCS. Periareolar mammaplasty: double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg 1996;97: Kinell I, Beausang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog s reduction mammaplasty: a follow-up study on 149 patients. Scand J Plast Reconstr Surg 1990;24: Kaye BL. Neurologic changes with excessively large breasts. 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10 mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg 1991;27: Pitanguy I. Reduction mammaplasty: a personal odysssey. In: Goldwyn RE, editor. Reduction mammaplasty. Boston: Little, Brown & Co; 1990: McKissock PK. Correction of macromastia by the bipedicle vertical dermal flap. In: Goldwyn RM, editor. Plastic and reconstructive surgery of the breast. Boston: Little Brown & Co; 1976; Mandrekas AD, Zambacos GJ, Anastasopoulous A, Haspas DA. Reduction mammaplasty with the inferior pedicle technique: early and late complications in 371 patients. Br J Plast Surg 1996;49: Bolger WE, Seyfer AE, Jackson SM. Reduction mammaplasty using the inferior glandular pyramid pedicle: experiences with 300 patients. Plast Reconstr Surg 1987;80: Lejour M. Vertical mammaplasty for breast hypertrophy and ptosis. Operative Tech Plast Reconstr Surg. 1996;3: Strombeck JL. Reduction mammaplasty by Strombeck technique. In: Goldwyn RM, editor. Plastic and reconstructive surgery of the breast. 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11 Goldwyn RM editor. Reduction mammaplasty. Boston: Little, Brown & Co; 1990: Krysander L. Reduction mammaplasty: comparison of results of plastic and general surgeons. Eur J Surg 1993;159: Goldwyn RM. Complications and undesirable results with reduction mammaplasty. In: Goldwyn RM, editor. The unfavorable result in plastic surgery: avoidance and treatment. 2nd ed. Boston: Little, Brown, 1984: Goin MK, Goin JM, Gianini MH. The psychic consequences of a reduction mammaplasty. Plast Reconstr Surg 1977;59: McKissock Keyhole Wire Pattern [package insert]. Kansas City, MO: Padgett Instruments Inc; 1998;12: McKissock PK. How I do it: reduction mammaplasty. Ann Plast Surg 1979;2: McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique: rationale and results. Clin Plast Surg 1976;3: Matarasso A, Pitanguy I. The keel resection/pitanguy reduction mammaplasty. Operative Tech Plast Reconstr Surg 1996;3: Georgiade GS, Riefkohl RE, Georgiade NG. The inferior dermal-pyramidal type breast reduction: long-term evaluation. Ann Plast Surg 1989;23: Dartigues L. Traitement chirurgical du prolapse mammaire. Arch Franco Belg Chir 1925;28: Lassus C. A technique for breast reduction. Int Surg 1970;53: Glatt BS, Sarwer DB, O Hara DE, Hamori C, Bucky LP, LaRossa D. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg 1999;103: Breast Reduction Techniques and Outcomes: A Meta-analysis A ESTHETIC S URGERY J OURNAL ~ JULY/AUGUST