reduction mammoplasty

Breast reduction 2015Breast reduction 2015

Dr sumer yadavDr sumer yadav Mch plastic and reonstructive surgeryMch plastic and reonstructive surgery

Dr sumer yadav - mch plastic surgeon , Dr sumer yadav - mch plastic surgeon , sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Breast is the symbol of femininity .It is a Breast is the symbol of femininity .It is a source of maternal and sexual feelings source of maternal and sexual feelings and is often the initiating focus of sexual and is often the initiating focus of sexual intimacy. Its feel, sensation and intimacy. Its feel, sensation and appearance, nurture the development of appearance, nurture the development of warm, interpersonal relationshipwarm, interpersonal relationship

DefinitionDefinition

Surgical reduction of breast volume to Surgical reduction of breast volume to achieve a smaller, aesthetically shaped achieve a smaller, aesthetically shaped breast mound with concomitant relief of breast mound with concomitant relief of the potential symptoms of mammary the potential symptoms of mammary hypertrophyhypertrophy

Breast EmbryologyBreast Embryology

Breast AnatomyBreast Anatomy

History History

Strombeck(1960)-Horizontal bipedicleStrombeck(1960)-Horizontal bipediclePitanguy,Weiner(1962)-superior pediclePitanguy,Weiner(1962)-superior pedicleSkoog(1963)-Superolateral pedicleSkoog(1963)-Superolateral pedicleMcKissock(1972)-Vertical bipedicleMcKissock(1972)-Vertical bipedicleCourtiss,Goldwyn, Georgiade, Ribiero, Courtiss,Goldwyn, Georgiade, Ribiero, Robbins(1975-1977)- Inferior pedicleRobbins(1975-1977)- Inferior pedicleOrlando(1975)-superomedial pedicleOrlando(1975)-superomedial pedicleBiesenberger(1928),Hester(1985) – central Biesenberger(1928),Hester(1985) – central moundmound

Contd. Contd. Vertical and short scar techniques Vertical and short scar techniques

Vertical scar -Lassus, Lejour, Vertical scar -Lassus, Lejour, Hammond(SPAIR), Hall Findlay (1970 - Hammond(SPAIR), Hall Findlay (1970 - 1999)1999) Vertical scar with short inframammary scar –Vertical scar with short inframammary scar –Marchac peixoto(1980-1982)Marchac peixoto(1980-1982)B or J scar reduction – Regnault & B or J scar reduction – Regnault & Chiari(1970-1974)Chiari(1970-1974) Periareolar reduction – Periareolar reduction – Benelli,Sampao-Benelli,Sampao-Goes (1990-1996) Goes (1990-1996)

Evaluation Of Breast EnlargementEvaluation Of Breast Enlargement

HistoryHistorySymptomsSymptomsRisk factorsRisk factorsScarring tendencies Scarring tendencies Reasons for wanting surgeryReasons for wanting surgeryh/o nipple sensationh/o nipple sensationSmoking historySmoking historyType of workType of workGeneral medical conditionGeneral medical condition

ProblemProblem

Macromastia-is developmental increase in Macromastia-is developmental increase in breast volume & weight. Reduction breast volume & weight. Reduction mammoplasty is indicated for symptomatic mammoplasty is indicated for symptomatic relief as well as aesthetic improvement relief as well as aesthetic improvement

EtiologyEtiology

MutifactorialMutifactorial -genetic-genetic -obesity-obesity -pregnancy-pregnancyVirginal hypertrophyVirginal hypertrophyGigantomastia Gigantomastia

Physical ExaminationPhysical ExaminationComplete general examinationComplete general examination

Local breast examinationLocal breast examination

-previous breast surgery-previous breast surgery -expected reduction volume-expected reduction volume -nipple-areola size &shape-nipple-areola size &shape -asymmetry-asymmetry -nipple sensation-nipple sensation -right & left nipple to sternal notch -right & left nipple to sternal notch

measurement measurement -right to left nipple to inframammary fold -right to left nipple to inframammary fold

measurement measurementDr sumer yadav - mch plastic surgeon , Dr sumer yadav - mch plastic surgeon , sumeryadav2004@gmail.comsumeryadav2004@gmail.com

InvestigationsInvestigations

RoutineRoutine

SpecificSpecific - Mammography - > 35 yrs.- Mammography - > 35 yrs. -Ultrasound evaluation-Ultrasound evaluation - Psychological evaluation & counseling- Psychological evaluation & counseling

Pre-op PhotographsPre-op Photographs

Front & lateral viewFront & lateral viewMarks at the normal nipple heightMarks at the normal nipple heightNipple in relation to elbowNipple in relation to elbowShoulder groovesShoulder grooves

TREATMENT PLANNINGTREATMENT PLANNING

Indications for surgeryIndications for surgery

Major Major – very large breast– very large breast shoulder painshoulder pain cervical & upper thoracic paincervical & upper thoracic pain

severe embarrassmentsevere embarrassment recurrent intertrigorecurrent intertrigo

Minor Minor – inability to exercise due to breast – inability to exercise due to breast discomfortdiscomfortdifficulty with breathing during difficulty with breathing during

exerciseexercisegrooving & hyper pigmentation of grooving & hyper pigmentation of shoulder strap areasshoulder strap areas

ContraindicationsContraindicationsAbsolute-Absolute-extreme obesityextreme obesity inadequate cardiac, pulmonary, inadequate cardiac, pulmonary, renal reserverenal reserve current or recent lactationcurrent or recent lactation unevaluated breast mass or unevaluated breast mass or mammographic findings mammographic findings

Relative Relative - current smoking history- current smoking history > 30% ideal body wt. obesity> 30% ideal body wt. obesity inappropriate psychiatric evaluationinappropriate psychiatric evaluation Dr sumer yadav - mch plastic surgeon , Dr sumer yadav - mch plastic surgeon ,

sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Selection of techniqueSelection of technique

Depends onDepends on- beast size- beast size- estimated resection volume- estimated resection volume- breast shape- breast shape- more elusive concept of - more elusive concept of appearance appearance

Selection of techniqueSelection of technique

Breast hypertrophyBreast hypertrophy Mild - (resection < 200gm./ side)Mild - (resection < 200gm./ side) Moderate - (resection 200-500gm./ side)Moderate - (resection 200-500gm./ side) Severe - (resection 500-1500gm./ side) Severe - (resection 500-1500gm./ side) Gigantic - (resection > Gigantic - (resection > 1500gm./ side)1500gm./ side)

Operative techniqueOperative technique

Liposuction- assisted reductionLiposuction- assisted reductionWise pattern marking designWise pattern marking design

McKissock vertical bipedicle McKissock vertical bipedicle techniquetechnique

Petanguy superior pedicle techniquePetanguy superior pedicle technique Inferior pyramidal pedicle techniqueInferior pyramidal pedicle technique Free nipple graft techniqueFree nipple graft technique Central parenchymal pedicle Central parenchymal pedicle

techniquetechniqueDr sumer yadav - mch plastic surgeon , Dr sumer yadav - mch plastic surgeon ,

sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Short scar techniqueShort scar technique Vertical MammoplastyVertical Mammoplasty Hall-Findlay Vertical scar MammoplastyHall-Findlay Vertical scar Mammoplasty Vertical reduction with short horizontal scarVertical reduction with short horizontal scar Marchac(1982)Marchac(1982) L-shaped scar reductionL-shaped scar reduction B techniqueB technique Horizontal scar reductionHorizontal scar reduction Periareolar reductionPeriareolar reduction Benelli round block procedureBenelli round block procedure Goes procedureGoes procedure Hammond SPAIR techniqueHammond SPAIR technique

Liposuction- assisted reductionLiposuction- assisted reductionGrazer & Teimourian (1985 )Grazer & Teimourian (1985 )Matarasso & Courtiss (1991)Matarasso & Courtiss (1991)Selection criteriaSelection criteria– Elastic skin & predominantly fatty breastElastic skin & predominantly fatty breast– Wishing conservative reductionWishing conservative reduction

Advantages Advantages – Preserve the glandular tissues, vessels, & nervesPreserve the glandular tissues, vessels, & nerves– If used as adjunct with reduction surgery reduces If used as adjunct with reduction surgery reduces

blood lossblood loss

Liposuction- assisted reductionLiposuction- assisted reduction

Wise pattern marking designWise pattern marking design

HistoryHistory– Modification of Strombeck procedure(1972)Modification of Strombeck procedure(1972)AdvantagesAdvantages– Well vascularised pedicleWell vascularised pedicle– Excellent exposureExcellent exposure– Maintenance of superior pole massMaintenance of superior pole mass– Good long term result with breast shapeGood long term result with breast shape– Flexibility in designFlexibility in designDisadvantagesDisadvantages– Sensory return – 65% Sensory return – 65% – Nipple retractionNipple retraction

Biesenberger reductionBiesenberger reduction

STROMBECK HORIZONTAL BIPEDICLE TECHSTROMBECK HORIZONTAL BIPEDICLE TECH

Pitanguy superior pedicle techniquePitanguy superior pedicle technique

HistoryHistory– Arie(1957) – first describedArie(1957) – first described– Ivo Petanguy (1967) – modification Ivo Petanguy (1967) – modification AdvantagesAdvantages– Best applied to breast reduction < 500gmBest applied to breast reduction < 500gm– Excellent long term breast shapeExcellent long term breast shape– Well vascularised pedicleWell vascularised pedicle– Preservation of nipple sensationPreservation of nipple sensation– Lack of interference with breast feedingLack of interference with breast feeding

pitanguypitanguy

Inferior pyramidal pedicle techniqueInferior pyramidal pedicle technique

HistoryHistory– Georgiade et al (1979)Georgiade et al (1979)AdvantagesAdvantages– Very versatile – use for reduction from 300-1500gmVery versatile – use for reduction from 300-1500gm– Long lasting result even with ptosis & macromastiaLong lasting result even with ptosis & macromastia– Well vascularised pedicleWell vascularised pedicle– Less chances of nipple retractionLess chances of nipple retraction– Excellent glandular exposureExcellent glandular exposure– Maintenance of nipple sensibility Maintenance of nipple sensibility CriticismCriticism– Flat breast with inadequate projectionFlat breast with inadequate projection

SUPEROMEDIAL PEDICLE WITH WISE PATTERNSUPEROMEDIAL PEDICLE WITH WISE PATTERN

Free nipple graft techniqueFree nipple graft techniqueProcedure of choice in the treatment of Procedure of choice in the treatment of gigantomastiagigantomastiaIt is a composite graft of skin, smooth muscle & It is a composite graft of skin, smooth muscle & ductal elementsductal elementsAdvantagesAdvantages– Rapid execution with minimal blood lossRapid execution with minimal blood loss– Maintenance of glandular shapeMaintenance of glandular shapeDisadvantagesDisadvantages– Loss of nipple sensibilityLoss of nipple sensibility– Loss of lactating abilityLoss of lactating ability

Free nipple graft techniqueFree nipple graft technique

Schwarzmann tech Schwarzmann tech

Central parenchymal pedicle Central parenchymal pedicle techniquetechnique

HistoryHistory– Hester & associates (1985)Hester & associates (1985)– Modified technique Biesenberger (1928) & Wise Modified technique Biesenberger (1928) & Wise

(1956,1963)(1956,1963)AdvantagesAdvantages– Well vascularised pedicleWell vascularised pedicle– Minimal difficulty with nipple transpositionMinimal difficulty with nipple transposition– Minimal pre-operative markingsMinimal pre-operative markings– Preservation of breast feeding & lactationPreservation of breast feeding & lactation– Preservation of nipple-areola sensationPreservation of nipple-areola sensation

DisadvantagesDisadvantages– Experience is required to perform freehand reductionExperience is required to perform freehand reduction

Central mound tech by hesterCentral mound tech by hester

Vertical MammoplastyVertical Mammoplasty

Lassus(1964) emphasizedLassus(1964) emphasized– Use of superior pedicle, inferior pyramidal Use of superior pedicle, inferior pyramidal

glandular resection, no skin undermining & glandular resection, no skin undermining & closure with a vertical scar only closure with a vertical scar only

Lejour(1999) Lejour(1999) – Modified Lassus techniqueModified Lassus technique– Prior liposuction of the breastPrior liposuction of the breast– Superior pedicle for the nipple-areola complexSuperior pedicle for the nipple-areola complex– Lower pole resectionLower pole resection– New breast mound from suture plication of New breast mound from suture plication of

lateral pillarslateral pillarsDr sumer yadav - mch plastic surgeon , Dr sumer yadav - mch plastic surgeon , sumeryadav2004@gmail.comsumeryadav2004@gmail.com

LISTA TECH……………………LISTA TECH……………………

LISTA TECHLISTA TECH

Hall-Findlay Vertical scar Hall-Findlay Vertical scar MammoplastyMammoplasty

Variation of vertical scar themeVariation of vertical scar themeMedial pedicle with inferolateral gland Medial pedicle with inferolateral gland resectionresectionParticularly effective for small to moderate Particularly effective for small to moderate reductionreductionForms a conical, well supported breastForms a conical, well supported breast

Hall-Findlay Vertical scar Hall-Findlay Vertical scar MammoplastyMammoplasty

Vertical reduction with short horizontal Vertical reduction with short horizontal scarscar

Marchac (1982)Marchac (1982)Central resection with vertical closure Central resection with vertical closure having a horizontal component was an having a horizontal component was an integral part of the pre-operative skin integral part of the pre-operative skin resection designresection design

Marchac(1982)Marchac(1982)

B & L-shaped scar reductionB & L-shaped scar reduction

Regnault (1974) – B technique Regnault (1974) – B technique mammoplasty that eliminated the medial mammoplasty that eliminated the medial component of the horizontal scarcomponent of the horizontal scar– Nipple is preserved on superomedial pedicleNipple is preserved on superomedial pedicle– Inferolateral glandular resectionInferolateral glandular resection

Born (1994) - modified L scar techniqueBorn (1994) - modified L scar technique– Medial triangular flap interdigitating with Medial triangular flap interdigitating with

lateral rectangular flaplateral rectangular flap

L-shaped scar reductionL-shaped scar reduction

B techniqueB technique

Horizontal scar reductionHorizontal scar reduction

Passot – first surgeon to describe Passot – first surgeon to describe horizontal scar reductionhorizontal scar reduction– Inferior wedge resectionInferior wedge resection– Nipple transposition in button hole incision Nipple transposition in button hole incision

higher up on the breast moundhigher up on the breast mound

Periareolar reductionPeriareolar reduction

Bennelli (1990) round block procedureBennelli (1990) round block procedure– Minimize scarringMinimize scarring– Skin taken up in purse string mannerSkin taken up in purse string manner– Drawback- flattening of breast in Drawback- flattening of breast in

anteroposterior dimension (pancake look)anteroposterior dimension (pancake look)

Peri-areolar reductionPeri-areolar reduction

Goes procedure (1996) – double skin Goes procedure (1996) – double skin techniquetechnique– Elevation of fairly thin skin flapsElevation of fairly thin skin flaps– Removal of superior horizontal wedge with Removal of superior horizontal wedge with

vertical upper pole wedgevertical upper pole wedge– Exposed central pedicle supported with Vicryl Exposed central pedicle supported with Vicryl

meshmesh

Hammond SPAIR techniqueHammond SPAIR technique

SPAIR – HAMMONDSPAIR – HAMMONDSHORT SCAR PERIAREOLAR INFERIOR PEDICLE REDUCTIONSHORT SCAR PERIAREOLAR INFERIOR PEDICLE REDUCTION

Sculpted pillar vertical reduction mammaplastySculpted pillar vertical reduction mammaplastyKent K. Higdon and James C. GrottingKent K. Higdon and James C. Grotting

Special topics in breast Special topics in breast reductionreduction

Secondary breast reductionSecondary breast reduction– Increase in breast volumeIncrease in breast volume– Poor shape or asymmetryPoor shape or asymmetry– Recurrent symptomsRecurrent symptomsAdolescent breast reduction for juvenile Adolescent breast reduction for juvenile hypertrophy – wait until breast growth hypertrophy – wait until breast growth stable for at least 1yrstable for at least 1yrOncoplastic breast reductionOncoplastic breast reduction– Advocated by Adretsch & CloughAdvocated by Adretsch & Clough

ComplicationsComplicationsHematoma - < 1%Hematoma - < 1%Seroma - 1-5%Seroma - 1-5%Infection - cellulitis or abscessInfection - cellulitis or abscessSkin necrosisSkin necrosisFat necrosisFat necrosisNipple lossNipple lossNipple numbnessNipple numbnessHypertrophic scarsHypertrophic scars

ComplicationsComplications

AsymmetryAsymmetryInadequate reduction or over reductionInadequate reduction or over reductionBoxy breast deformityBoxy breast deformityRecurrent enlargementRecurrent enlargementInability to breast feedInability to breast feedDog – earsDog – earsInadequate mastopexy resultInadequate mastopexy result

Thank youThank you

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