Special Topic Alexandre de Souza, MD; and Renato Saltz, MD Background: The evolution of breast reduction surgery is discussed to shed light on the various principles and techniques used in this 4-step procedure. Objective: The purpose of this article is to simplify planning for breast reduction and help teach the essential elements of an effective procedure to young surgeons while avoiding confusion about the many personal techniques being used today. Methods: The 4-step surgical approach to breast reduction, common to more than 70 different techniques, consists of vertical resection, horizontal resection, development of medial and lateral flaps, and development of the nipple areola flap. Results: This procedure effectively reduces the diameter and profile projection of the breast, provides better contour, and repositions the nipple. Conclusions: An in-depth understanding of the 4 basic principles involved in breast reduction will make the procedure easier to perform and lead to more predictable results. An estimated 40,000 breast reduction procedures were performed in the United States in 1988 1 ; the number had doubled by 1999. 2 A search of the literature in breast reduction techniques reveals approximately 400 papers describing 72 different techniques. These procedures have basic similarities that may sometimes be obscured by their technical differences. The diversity of methods and the large number of surgeons involved in the development of breast reduction surgery over the years make it difficult to present a complete history of the surgical evolution of the procedure. Nevertheless, some historical points will be mentioned here to provide a basis for surgical decision-making. A historic review of breast reduction techniques reveals an initial preoccupation with volume. Today, the goals of breast reduction have evolved to include optimal shape, minimal scarring, and preservation of the sensibility and function of the breast. Evolution According to Letterman and Schurter, 3 the first breast reduction was performed by Paulus Aegineta (AD 625-690) for the treatment of gynecomastia. In 1882, Guinard 4 described a mastopexy in which he reduced the breast volume and affixed the breast to the ribs. In 1903, Morestin 5 reported on his use of nipple-areolar complex grafts in breast reductions; 4 years later, the same author described a reduction through an incision in From Roane General Hospital, Spencer, WV (Dr. de Souza); and the University of Utah Medical Center, Salt Lake City, UT (Dr. Saltz). Accepted for publication April 21, 2000. Reprint requests: Renato Saltz, MD, University of Utah Medical Center, 50 N. Medical Drive, #3B205, Salt Lake City, UT 84132. Copyright 2000 by The American Society for Aesthetic Plastic Surgery, Inc. 1084-0761/2000/$12.00 + 0 70/1/108382 doi:10.1067/maj.2000.108382 A ESTHETIC S URGERY J OURNAL ~ MAY/JUNE 2000 213
the inframammary sulcus. 6 The classic inverted T incision was first described by Lexer 7 in 1912. He also performed resections of breast tissue and transposition of the nippleareolar complex to lift the breast. This technique was the precursor to the modern inverted T reduction. In 1916, Kraske 8 performed a mammaplasty through a periareolar incision and reported extensive necrosis. This study brought to notice the need for preservation of the dermal plexus as a blood supply for the nipple-areolar complex. During the 1920s, several techniques were described by Hollander, Joseph, De Quervain, Kuster, Noel, Virenque, and many others. In 1930, Schwarzmann described undermining the periareolar skin while leaving the dermal plexus of the nipple-areolar complex intact. May 9 presented a technique involving an independent approach to the skin envelope and underlying breast tissue; both the breast parenchyma and the nipple-areola complex were covered with skin before final resection. Wise 10 and Strombeck 11 used similar techniques with the application of a pattern for skin incision, Schwarzmann maneuver, and inferior dermoglandular resections. Both techniques involved nippleareola complexes vascularized on superior pedicles. At the same time, Pitanguy 12 and Arie 13 presented techniques of reduction in which vertical and inverted T skin incisions were used. They also popularized a vertical breast parenchymal resection below the nipple-areola complex, leaving this complex based on a superior pedicle. Several others, including Skoog in Sweden, also used a superior pedicle. These authors stressed the need to preserve the medial and lateral pillars to obtain a better cone shape and improved projection. In contrast to those who used the classic mathematical methods, Pitanguy 12 suggested marking the breast on a case-by-case basis. He identified a point A at the intersection of the existing inframammary sulcus and the apex of the imaginary cone. McKissock 14 described a bipedicle breast reduction technique involving the use of an inverted T incision and folded pedicle to obtain more projection. 13 The parenchymal resections are performed laterally and medially to the bipedicle flap. In 1979, Georgiade et al 15 reviewed 218 cases of breast reduction and compared several types of pedicles superior, inferior, and bipedicle; the authors preferred the inferior pedicle. The 1980s were marked by attempts to reduce scars without compromising the principles of ideal shape and projection that are achieved with the more classic techniques. Marchac and de Olarte 16 in France and Peixoto 17 in Brazil were proponents of reduction with the small inverted T. The latter also resected the base of the breast to decrease projection. Sepulveda, Bozzola et al, 18 and Chiari 19 described L and J techniques. More recently, Bustos demonstrated a periareolar approach. Melvin and Erol 20 have used this technique for the last 10 years. McKissock, Goldwin, Le Jour, Goes, and many other authors have reported various breast reduction techniques in which great success was achieved. Each of these techniques depends on 2 or more of the 4 common principles that we describe in this article, and the success is due partly to the rich blood supply found in the breast. The anatomic basis Half a century ago, Maliniac 21 studied 103 female breasts and demonstrated a large intercommunication among the internal mammary, lateral thoracic, and intercostal arteries, forming a rich circular plexus. This work was later confirmed by Tracy et al, 22 who studied blood flow changes during breast reductions using Doppler flow cytometry and demonstrated that several different reduction techniques do not compromise the blood supply of the breast. In 1993, Daher, 23 recognizing the importance of maximizing the number of perforator branches to improve the blood supply of the breast, offered several different pedicle and flap possibilities. He demonstrated that 52.28% of these perforators emerge from the hemiclavicular line, 28.57% from the sternal line, and 19.95% from the anterior axillary line. New concepts of breast parenchyma resection reinforce the idea that the skin envelope can be resected independently of the breast tissue because the subcutaneous plexus can nourish large skin flaps. Therefore, different skin resections can be combined with different tissue resections (Figure 1) to treat a variety of breast deformities. Surgical Technique This section describes a series of maneuvers based on an anatomic analysis of the breast. We have identified and described the common, basic principles responsible for the success of all modern reduction techniques. An initial anatomic diagnosis of the patient s breast based 214 A ESTHETIC S URGERY J OURNAL ~ MAY/JUNE 2000 Volume 20, Number 3
on a series of parameters determines our surgical plans. An understanding of the blood supply of the breast and the unique relationship between glandular tissue and the skin envelope have led us to propose a more simplified surgical plan for breast reduction. A B Step I (A and B). Breast is lifted by point A. Deepithelialization of the breast flap and vertical resection for decrease in breast width. Geometric representation of the resected cone. Once the diagnosis of the breast deformity is made, a 4-step surgical approach is used for the reduction (Figure 1). The skin envelope and the breast parenchyma are treated independently. Step I: vertical resection The first step includes the reduction of breast parenchyma and adjustment of the skin envelope (Figure 1, A and B). The choices for skin resection include the inverted T technique for large breasts, the L shape for medium-size breasts, and the periareolar incision for small breasts. We used the L incision in the case example (presented in the section that follows) because of the size and asymmetry of the breast. In our experience, the type of incision should be determined on a case-bycase basis. A small-scar technique may not allow for an optimal breast shape. A periareolar incision may lead to a less well-defined cone shape with less projection. Figure 1. The 4-step approach. Step II: horizontal resection This step allows the amputation of the base of the breast to improve the proportion between the breast and body profile. The resection of the base of the breast decreases the projection, especially in cases with parenchymal hypertrophy (Figure 1, C-E). In our case example, the resection was 0.2 cm in thickness at the base. C D E F H G I Step II (C-E). Breast is resected in the base to decrease the breast length. Geometric representation of the amputated base. Step III (F and G). Release of the medial and lateral flaps with rotation and overlapping to create a more defined contour. Step IV (H and I). Release and rotation of the lateral or medial superior pedicle in order to fill the upper aspect and correct the ptosis of the breast. Step III: development of the medial and lateral flaps The goal of the development of the medial and lateral flaps is to provide breast contour (Figure 1, F and G). The flaps, as developed by De Souza and Psillakis in 1988, defined resection limits. Laterally, the limit is defined by the subcutaneous plexus; posteriorly, the surgeon must preserve approximately 2 to 3 cm to avoid damage at the level of the fourth intercostal nerve and preserve the sensibility of the nipple-areola complex. In our experience, a flap 2.5 to 3 cm deep is sufficient to produce a pleasant lateral and medial contour without risk of damage to the blood supply of the skin or denervation of the nipple and areola. Step IV: development of the nipple-areola complex Our preference is for the superior pedicle; however, inferior and lateral pedicles are acceptable. The pedicle is transposed toward point A for permanent nipple-areola complex positioning and correction of ptosis (Figure 1, A ESTHETIC S URGERY J OURNAL ~ MAY/JUNE 2000 215
A B nipple-areola complex; (4) severe ptosis with nipple-areola complex positioned below the inframammary line, more severe on the right side; (5) breast contour poorly defined, with excess breast tissue at the axillary tail and inferiorly; (6) lack of breast tissue superiorly and medially; (7) poor projection; and (8) poorly defined limits of the breast at the abdominal and axillary borders (Figure 2). C E G Figure 2. A, C, E, Preoperative views of a 26-year-old woman. G, H, Postoperative views immediately after the L-scar technique. B, D, F, Postoperative views 1 year after the L-scar technique. H and I). When it is based laterally, this pedicle has a safe blood supply from the midclavicular perforators and from the subcutaneous plexus. Case Example To illustrate our approach, we present a case study, beginning with a critical anatomic diagnosis of a patient s breast. This diagnosis involves the following parameters: (1) breast-body relationship; (2) symmetry; (3) shape and location of the nipple-areola complex; (4) relationship between the inframammary sulcus and the nipple-areola complex; (5) breast contour (medial, superior, inferior, and lateral lines); (6) projection; and (7) relationship between the breast and the chest wall. In this patient, the findings were as follows: (1) breast hypertrophy; (2) right breast larger than the left breast, with wide bilateral bases; (3) left nipple-areola complex deviated medially and smaller in diameter than the right D F H The operative markings are made with the patient sitting on the operating table at a 45-degree angle. This maneuver avoids the distortion that gravity can cause on breasts of the same size but with different amounts of fat and glandular tissue. Point A is the projection of the inframammary line transposed to the anterior breast wall. Points B and C are on the medial and lateral edges (based on the breast-pinching maneuver) and average approximately 120 degrees (± 20 degrees) from point A. The edges are approximately 8 cm long (± 1 cm) from point A. The management of the skin envelope (step I) can be performed through an inverted T incision for large breasts, an L-shaped incision for medium breasts, or a periareolar incision for small breasts. In this patient, an L incision was performed because of the breast size and, in particular, because of the breast asymmetry. Small incisions improve the quality of the scar but may compromise shape and projection. After the skin resection is complete, the parenchymal reduction is performed beginning with step I. The medial and lateral flaps developed during step III can be rotated, approximated, or overlapped to produce a well-defined breast contour. It is important to preserve the subcutaneous plexi during the medial and lateral flap dissections to preserve adequate blood supply to the skin envelope. The dissection of the breast parenchyma from the pectoralis fascia should be extensive, freeing the entire breast tissue from the chest wall up to the limit of the fourth intercostal branch. This maneuver compromises neither the blood supply nor the innervation of the nipple-areola complex. The base amputation of the breast tissue is parallel to the chest wall and is extended through the entire breast. Conclusion This study identifies the 4 basic principles common to all breast reduction techniques. Although more than 70 different techniques have been described, all of them have several steps in common. The principles focus on the shaping of the breast parenchyma with vertical and horizontal resections, the development of small lateral and medial flaps to maximize contour, and the development 216 A ESTHETIC S URGERY J OURNAL ~ MAY/JUNE 2000 Volume 20, Number 3
of the pedicle that carries the nipple-areola complex. Resection and shaping of the parenchyma is performed independently from the skin envelope. Once the parenchyma is sculpted, the skin envelope is adjusted to fit the new breast. The skin can be incised in an L, in an inverted T, periareolarly, or vertically, regardless of the parenchymal resection, and the choice of incision is dependent on the amount of skin to be removed. An understanding of the basic principles of breast reduction makes this procedure more reliable and easier to perform and gives the surgeon more freedom to orient the pedicle to the nipple-areola complex. This freedom translates ultimately to better cosmetic results. References 1. 1988 Plastic Surgery Statistics Fact Sheet. Arlington, IL: The American Society of Plastic and Reconstructive Surgeons; 1989. 2. 1999 Statistics. New York: The American Society for Aesthetic Plastic Surgery; 2000. 3. Letterman G, Schurter M. The surgical correction of gynecomastia. Am Surg 1969;35:322. 4. Guinard A. Discussion of report by Morestin on the removal of benign tumors of the breast. In: Bull et Mem Soc de Chir. Paris, France: Leay; 1923. 5. Morestin H. Bull Soc Chir 1905:29. 6. Morestin H. Bull Soc Chir 1907:33. 7. Lexer E. Hypertrophy of the breast. Munchen Med Wchnschr 1912;59:2702. 8. Kraske M. Ole operationen der atrophischen und hypertrophischen hangebrust. Munchen Med Wchnschr 1923;70:672. 9. May H. Reconstruction of breast deformities. Surg Gynecol Obstetr 1943;77:523. 10. Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg 1956;17:367. 11. Strombeck JD. Reduction mammaplasty. In: Grabb WC, Smith JW, eds. Plastic Surgery: A Concise Guide to Clinical Practice. Boston, MA: Little, Brown and Company; 1968. 12. Pitanguy I. Surgical correction of breast hypertrophy. Br J Plast Surg 1967;20:78. 13. Arie G. Ona noeva technica de mastoplastia. Rev Iber Launo Am Cir Plast 1957;3:28. 14. McKissock PK. Reduction mammaplasty by the vertical bipedicle flap technique: rationale and results. Clin Plast Surg 1976;3:309. 15. Georgiade NG, Serafin D, Morris R, Georgiade D. Reduction mammaplasty utilizing an inferior pedicle nipple areolar flap. Ann Plast Surg 1979;3:211. 16. Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with a short inframammary scar. Plast Reconstr Surg 1982;69:45. 17. Peixoto G. Reduction mammaplasty. Aesthetic Plast Surg 1984;8:231. 18. Bozzola AK, Oliverira HC, Sanchez WH, et al. Mamoplastia em L: contribuicao Pessoal R. Amriggs. Porto Alegre 1982;26:207. 19. Chiari A Jr. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg 1992;90:233. 20. Erol OO, Spira M. A mastopexy technique for mild to moderate ptosis. Plast Reconstr Surg 1980;65:603. 21. Maliniac JW. Arterial blood supply of the breast. Arch Surg 1943;47:329. 22. Tracy CA, Poole R, Gellis M, Vasileff W. Blood flow of the areola breast skin flaps during reduction mammaplasty as measured by Doppler flowmetry. Ann Plast Surg 1992;28:160. 23. Daher JC. Breast island flaps. Ann Plast Surg 1993;30:223. A ESTHETIC S URGERY J OURNAL ~ MAY/JUNE 2000 217