Breast Reduction By Dr. Tarek Ahmed Said Professor of Plastic Surgery Cairo University 2017

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Breast Reduction By Dr. Tarek Ahmed Said Professor of Plastic Surgery Cairo University 2017

Reduction Mammaplasty SAFE Good Size Reduction Minimal Scar Aesthetic & Long Lasting Breast Shape

Reduction Mammaplasty Reduce Size, improve shape and position Maintain Vascular Supply Maintain Nerve Supply Maintain Ductal Integrity & Lactation Potential

Anatomy

BREAST SEPTUM

Techniques 4 Basic Elements 1. Pedicle 2. Skin Envelope (SCARS) 3. Parenchymal Excision 4. Breast Shaping (Redraping / Pillars / Sutures)

Pedicles Bipedicle (McKissock) Single Pedicle Inferior Pedicle (Robbins) Superior Pedicle (Wiener) Superomedial Pedicle (Orlando & Gutherie) Central Mound Pedicle Medial Pedicle Lateral Pedicle Septal Based Mammaplasty (Medial or Lateral) Breast Amputation & Free Nipple & Areola Graft

Inferior & Central Pedicles Intercostal perforators / Deep branch of 4 th intercostal nerve Adv: More Reliable Vascularity / Preserves sensation and lactation potential Disadv: Bottoming Out / Lower Fullness Disadv: Time consuming deepithelization Superior Pedicle Thoracoacromial A / Supraclavicular Nerves Adv: No Bottoming out Disadv: Less Reliable Vascularity: Pedicle thinned & separated from chest wall + Pedicle Kinking Disadv: Limited to Moderate Sized Breast (limited nipple elevation) Disadv: Affects Sensation and Lactation Superomedial (& Medial) Pedicles Thoracoacromial + Internal Mammary A / Supraclavicular N. +/- (4 th intercostal if septum included) Adv: No Bottoming out / No Kink Adv: Further Nipple Transposition (No size limitation) Disadv: May Affect Sensation and Lactation Lateral Pedicle Lateral thoracic artery / Deep branch of 4 th intercostal nerve Adv: Better Sensation (Deep branch of 4 th intercostal) & Vascularity Adv: No Bottoming out / No Kink Adv: Further Nipple Transposition (No size limitation) Disadv: Lateral Breast Fullness (can be avoided by septal based lateral pedicle)

Skin Patterns Inverted T Mammaplasty [Skin Redraping / Pilars] - Inferior Pedicle (Robbins) - Superior Pedicle (Wiener) - Superomedial Pedicle (Orlando & Gutherie) - Central Mound Pedicle - Medial Pedicle - Lateral Pedicle Vertical Scar Mammaplasty [Over correction] +/- [short transverse scar] [Suspension / Pillar Plication] - Superior Pedicle: Lassus Lejour-Abboud - Superomedial (or Superolateral) Pedicle: Hall-Findlay - Septal Based (Lateral or Medial): Hamdi Circumvertical [Internal Shaping Sutures] - Inferior Pedicle: Short-scar Peri-Areolar Inferior Pedicle Reduction SPAIR - Superomedial Pedicle Short-Scar Peri-Areolar: Spear

Inverted T Mammaplasty - Long Horizontal Scar Vertical Scar Mammaplasty - Pushed up appearance which needs a long time to settle - Unpredictable shape - Limited to moderate sizes - With larger reductions vertical scar may settle down crossing IMF - Occasional need for revisional skin resection - Reduction dependant on liposuction which is not feasible in dense breasts

Vertical Lassus Lejour Lejour-Abboud added liposuction from all areas except behind pedicle and extensive lower skin undermining - Pushed up appearance which needs a long time to settle - Unpredictable shape - Limited to moderate sizes - With larger reductions vertical scar may settle down crossing IMF - Occasional need for revisional skin resection - Reduction dependant on liposuction which is not feasible in dense breasts Hall-Findlay Superomedial pedicle (May be superolateral) No tunnel, no separation of pedicle nor sutures to muscles Applied to Larger volumes All other Cons of Lejour

Circumvertical Hammond s SPAIR Vertical - Inferior Avoids Flatenning of areola Avoids bottoming out No limitation on nipple transposition Less skin wrinkles than Lejour Shape depend mainly on purse string suture Areolar Scar Widening Limited Volume reduction less than 1000 gm Lower breast fullness {like all inferior [pedicles} Time consuming depeithelization No Pillars Spear - Superomedial [Similar to Hammond but with Superomedial pedicle +/- a short transverse scar] Less bottoming out Easier gathering of Skin in lower breast No Pillars Extensice lateral undermining can lead to necrosis

Examination Breast Base Upper Pole Contour Lower Pole Skin Asymmetry Measurements Breast Base Midclavicle Nipple / Sternal Notch Nipple Inframammary Fold Nipple Areola Diameter Inframammary Fold Length Breast Weight

Inverted T Mammaplasty Marking

John Bostwick Jr. III 1-The midline of the breast is marked. 2-The upper edge of the new areola (Point A) 3-An inverted V is drawn form point A 4- Points B & C are marked 9 cms away from Point A 5-The inframammary fold is marked 6-Point D is marked 7-The expected shape of the new breast can be checked 8- Points B & C are joined by straight lines to points E & F 9-New areola is marked by a 3.8-4.2 mm circle

Parenchymal Excision Medial and Lateral wedges removed Extended excision minimal to none medially More resection laterally Don't open subscarpal space at IMF

Superior Pedicle

Superomedial Pedicle

Superomedial Pedicle More Blood Supply (Internal Mammary) Better Sensation (Ant.Cut. 2nd-5th) Lesser Tension Further Transposition

Superomedial Pedicle 1-The midline of the breast is marked. 2-The upper edge of the new areola (Point A) 3-An inverted V is drawn form point A 4- Points B & C are marked 9 cms away from Point A 5-The inframammary fold is marked 6-Point D is marked 7-The expected shape of the new breast can be checked 8- Points B & C are joined by straight lines to points E & F 9-New areola is marked by a 3.8-4.2 mm circle

Superomedial Pedicle

Superomedial Pedicle

Vertical Mammaplasty

Marking

Summary

Superior Pedicle: Less Vascularty / limited transposition Inferior Pedicle: Bottoming Out Inverted T: long inframammary transverse scar Vertical Mammaplasty Pedicle Separated from chest wall / Pushed up Appearance / Shape unpredictable / Need for secondary skin resection sometimes / Volume reduction depends heavily on liposuction which is not feasible in large dense breasts / Limited transposition Circumvertical Avoids Flatenning of areola / Avoids bottoming out / No limitation on nipple transposition / Less skin wrinkles than Lejour Shape depend mainly on purse string suture / Areolar Scar Widening / Limited Volume reduction less than 1000 gm / Lower breast fullness {like all inferior [pedicles} / Time consuming depeithelization / No Pillars

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