Breast Reduction, Nipple Grafting

Large, pendulous breasts, where much of the parenchyma is below the inframammary fold, require a different approach when considering a reduction procedure. This involves markings, anticipation of anatomic changes with reduction of weight and volume, and handling of the nipple-areola complex as a full-thickness skin graft.

Criteria of what constitutes a breast of this caliber vary among surgeons. McKissock suggested considering amputation mammaplasty for excisions of greater than a kilogram and/or where vertical pedicle lengths exceeded 35 cm.[1] These are only guidelines, and the final decision about the technique is made between the surgeon and patient.

As many techniques are available, the procedure can be tailored to the patient's desires in terms of shape and size. The patient needs to accept the inability to breastfeed and loss of nipple sensation following this technique. Reduction procedures can provide resolution of the functional and aesthetic problems associated with hypertrophic breasts.

Hawtof, in a retrospective study of 54 patients, revealed that none of the 19 patients who underwent grafting procedures had any complication.[2] In comparison, 6 of 35 patients who underwent pedicle procedures developed complications such as skin loss, dehiscence, nipple loss, or infection.

Amputation reduction procedures are associated with a high level of satisfaction, long-term preservation of shape, and resolution of symptoms.

Historically, the treatment of female breast hypertrophy has been surgical; the first technique was used over 100 years ago.[3]

In 1921, Thorek described the first deliberate attempt to transplant the nipple for cosmetic reasons.

Hormonal manipulations are ineffective, and weight reduction, while having a direct effect on breast size, does not change body proportion or breast position and has not been shown to consistently relieve the symptoms of breast hypertrophy.

According to the American Society of Plastic Surgeons (ASPS), the terms female breast hypertrophy or macromastia describe an increase in the volume and weight of breast tissue in excess of the normal proportion. This is usually symmetrical, but on occasion can be unilateral, such as in a postmastectomy patient or in a patient with benign juvenile hypertrophy. Excessive hypertrophy results in a disproportionate breast to body size.

Many females are genetically destined to have large breasts. This often is aggravated with pregnancy or weight gain. In addition, iatrogenic causes include asymmetry following a mastectomy.

Rarely, a young patient may experience virginal mammary hypertrophy resulting in massive breast hypertrophy and a high recurrence rate following a reduction-type procedure.

Women with macromastia or hypertrophy often present in a classic manner. They have larger than average, ptotic, dense breasts. Often, the patient is overweight with a wide chest and rolls of pannus over the abdomen.

The physician should inquire about previous breast trauma, spinal or neck injuries, and whether symptoms were absent when the patient weighed less. The presence of any of these indicates a more thorough evaluation may be needed. Weight loss prior to surgery may help improve a patient's problems and lead to a better surgical result.

Symptoms can be a result of muscle strains and postural changes causing headaches, backache, neck pain, shoulder pain, and nerve paresthesias.

Complaints may be related to breast weight, brassiere support resulting in shoulder grooving and ulceration, and breast pains.

Problems may be a related to hygiene (eg, intertrigo, acne, hidradenitis).

Of lesser concern to insurance companies are problems related to the restrictions large breasts place on an individual with regard to her participation in sports and exercise, and the social stigma leading to embarrassment, sexual harassment, and feelings of sexual inadequacy.

Finally, clothing may never fit right, necessitating custom-made clothes or alterations.

Shortness of breath is not considered secondary to macromastia. However, the sensation of difficulty breathing when supine is quite common.

Breast reduction surgery is indicated in any female who has voiced the aforementioned complaints and is free of complicating issues such as breast trauma, neck or back injury, or a history of resolution of symptoms with lower weight. In addition, improvement of symptoms by manual lifting of the breast suggests a successful outcome. In addition, a history of feeling better upon awakening and the subsequent progression of symptoms over the course of the day support the diagnosis of symptomatic macromastia.

Robbins[4] suggested this procedure for excisions greater than 1500 mL per breast, and Jackson[5] suggested that free nipple graft procedures are not indicated in these patients. This author feels that inferior pedicle techniques lead to long-term bottoming out and that the patient should make the final decision when presented the numerous options available.

With the technique described here, the patient must accept the inability to breastfeed and the loss of nipple sensation. In theory, this technique can remove a considerable amount of the mammary ducts and could be beneficial in helping diminish the risk of subsequent breast cancer. Free nipple grafting can be used in any situation in which nipple viability is questioned and the patient accepts the loss of sensation and inability to breast feed.

A retrospective study by Lo et al indicated that in patients who undergo breast reduction, free nipple grafting is more likely to be used in those in whom an average of more than 1500 g of tissue is removed from each breast (the likelihood being 1.4 times that of patients in whom less tissue is removed). In addition, individuals in the study who underwent free nipple grafting had a mean body mass index (BMI) of 37.6, versus 29.5 in those who did not, with 78.6% of the free grafting patients being obese, versus 46.0% of those in whom free grafting was not performed.[6]

With the proliferation and improvements with superior/medial pedicles, these techniques can always be attempted prior to resorting to a free nipple graft (due to obvious poor perfusion). The author now attempts this unless a nipple graft technique is obviously necessary (ie, extreme skin laxity or nipple excessively far from desired new position).

Insurance companies often dictate minimum weight excisions for coverage of breast reduction procedures; these requirements need to be met if the patient plans to use insurance to pay for the procedure.

Since the nipple is being transferred as a full-thickness graft, vascular insufficiency is not really a problem. Nerves to the nipple areolar complex are transected during harvesting of the nipple areolar complex. Incisions should not extend below the existing inframammary fold.

Dog ears are very common laterally if an anchor (WISE) pattern is used. Circular excisions with purse-string closure techniques are quite effective in minimizing this problem.

Breast shape varies among patients, but knowing and understanding the anatomy of the breast ensures safe surgical planning. For more information about the relevant anatomy, see Breast Anatomy.

Reduction mammaplasty is contraindicated in any female with suggestive or suspicious mammographic findings. Until those findings are resolved to the satisfaction of her treating physician, surgery should be delayed.

Surgery is also contraindicated if the patient is not willing to accept a smaller breast and the potential risks and complications that may result.

If nipple sensation is essential to a patient's intimacy and satisfaction, this surgery should not be performed.

The scars that normally result from this procedure also must be accepted completely without reservation.

Perform a complete blood count to ensure anemia (hemoglobin < 10 g) or thrombocytopenia are not present. (As blood loss with this procedure should be minimal, the author does not recommend autogenous banking of blood.)

Provide photographic documentation to the insurance company for authorization and for comparison of before and after photos to help the patient appreciate what has changed.

Other laboratory tests may be indicated depending on the additional health problems the patient may have or the medications she may be taking. This includes prothrombin time, activated partial thromboplastin time, complete or basic metabolic profiles, and urinalysis. An ECG is performed if indicated by the patient's history or if required by the surgical facility.

Mammography is indicated in any patient who is 40 years or older and has not undergone one in the prior 6-9 months. This is in compliance with the guidelines established by the American Cancer Society. The author also considers mammography in patients older than 30 years when they have a strong family history of breast cancer. Mammography (and possibly ultrasound or other imaging studies) is also used in the evaluation of palpable masses noted on physical examination. Postoperative baseline mammograms are obtained approximately 6 months after the surgery or at the discretion of the surgeon. This is to provide a baseline for comparison with future mammograms and document what changes may have occurred following surgical intervention.

Obtain chest radiographs if indicated by examination findings or the patient's history.

An ECG is performed if a patient's history warrants. In addition, some surgical facilities have guidelines requiring ECGs at certain patient ages.

Manual lifting of the breasts may result in considerable relief or resolution of symptoms. This is a strong indicator that the procedure will result in relief for the patient.

Progression of symptoms over the course of the day when upright and wearing a bra also support the probability of a health benefit following reduction surgery.

Tissue is sent for pathologic examination to rule out carcinoma or other atypia.

No medical treatment exists for female breast hypertrophy. However, weight loss may be encouraged if past experience of weight loss led to diminished or alleviated symptoms.

Orthotic devices may assist the patient but usually places more pressure on the shoulders.

Reduction mammaplasty is the only known method of diminishing the size of the breast.

McKissock described a very reliable method of marking a patient with the WISE pattern for reduction of very large breasts by free-nipple graft.[1]

In brief, the patient is marked in a sitting position. If the breasts are connected in the midline, a modification of the medial markings is necessary to allow a complete excision.

The sternal notch and midline are marked. A point is made on the right and left clavicle 7-8 cm away from the sternal notch. When these points are connected, it results in a level line.

The inframammary folds are marked, and the ink is allowed to dry before releasing the breasts.

Breast meridian lines are drawn in relation to the current nipple position by connecting the nipple to its respective clavicular mark.

Medial or lateral adjustments are made of these meridians until equidistant from the midline and over what is anticipated to be the widest part of the breast.

An obstetric caliper is used to help transpose the distance from the clavicular marking to the inframammary fold to the front of the breast along the previously drawn meridian.

Other techniques of transposing the inframammary fold to the anterior breast also can be used, eg, the use of the surgeon's finger in the fold. Other techniques may be equally as effective.

The nipple position, as determined by transposing the clavicle-fold distance to the front of the breast, is now modified by dropping the nipple position 1-2 cm along the meridian line, depending on the anticipated weight of the breast tissue to be removed. If the surgeon ignores this key step, the nipples will be pointing upwards after surgery with excessive lower pole fullness. McKissock describes a "springback" effect on the breast when the weight is removed.[1]

Confirmatory measurements should now be performed. Measurements from the sternal notch to each nipple should be near equal. Additional near equal measurements include the clavicular-nipple and nipple-midline distances. The nipple position should also appear level on visual inspection.

The WISE pattern (keyhole template) is then placed over the new nipple position and traced according to the surgeon's preference. This pattern can be rotated to avoid inclusion of the areola skin in the skin flaps.

Vertical techniques can also be utilized if the surgeon deems appropriate. This usually involves excision of lateral breast tissue, leaving a thick lateral flap to allow for an adequate excision. The remainder of this discussion is directed toward WISE pattern excisions.

The spread between the oblique limbs can vary, but pulling the medial breast laterally and the lateral breast medially to see if the vertical lines will meet can simulate closure. If these lines cannot meet, it would be prudent to retrace the pattern with less spread of the oblique limbs to ensure the ability to close the wound.

The length of the vertical limbs also varies depending on the patient's size and weight of her breasts. This can vary from 5-9 cm, with larger breasts requiring longer vertical limbs. If in doubt, start with a long limb and trim intraoperatively as needed.

A point is selected laterally to the breast where the breast mound appears to end and blend into the lateral thorax or lateral thoracic roll.

With the breast held up, this lateral point is drawn downwards medially, perhaps staying a centimeter above the existing inframammary fold.

This lateral point is also connected to the bottom of the lateral vertical limb with an S-shaped incision, starting almost perpendicular to the previously drawn line.

This allows more pull laterally, helping to flatten the usually protuberant lateral pole. The patient is then placed supine and the medial lines are drawn, connecting at a point under the medial breast fold.

View completed pattern markings on the patient.

If a central connection (nonexistent intermammary distance) exists between breasts, one can refer to Dr. McKissock's monograph Color Atlas of Mammaplasty. This sequence of demonstrative photographs is reprinted with permission from that monograph.[1]

In a meta-analysis based on three randomized, controlled trials, Shortt et al found that wound infections were reduced by 75% when preoperative antibiotics were used before breast reduction surgery.[7]

After induction of general anesthesia, the patient's arms are abducted 90° on padded arm boards and secured with Sof-Rol or Kerlix or a similar technique used to secure extremities.

Sequential compression devices are usually started prior to induction of anesthesia to prevent deep vein thrombosis and potential embolization.

A Foley catheter is placed at the discretion of the surgeon or anesthesiologist. The chest is prepared and draped in the usual fashion.

Xylocaine (1%) with epinephrine is injected along the planned incision lines to aid in hemostasis and minimize blood loss. This simple step remarkably reduces bleeding during the procedure.

A towel clip is used to hold the breast up, and a lap sponge is placed around the base of the breast, similar to commercial breast tourniquets. The nipple is harvested as a full-thickness graft after outlining the nipple-areolar complex with a Padgett nipple marker and stored in a saline sponge.

The new nipple position (graft site) is then de-epithelialized.

The inframammary incision is then made and carried down to the fascia, elevating the breast off the wall, until the inferior aspect of the retained breast flaps is reached. If the decision is to leave an inferiorly based, deepithelialized flap for enhancing projection, this step is performed first, then the transverse incision is made along previous markings and at the cephalad edge of the deepithelialized pyramid. This pyramid is centered under the anticipated vertical closure incision and its width is dependent on the amount of tissue that can be spared and how much projection is desired.

If the breasts are so large that leaving the central portion of the keyhole below the nipple graft site would not jeopardize meeting insurance company requirements, this skin can be deepithelialized and even transferred to sub-graft site similar to autoaugmentation techniques described by Ruth Graf, MD. This maneuver also helps with nipple projection.

Other techniques to help improve breast projection include the following:

• As mentioned above, Koger suggested a technique that involves preserving an inferior-based (along the inframammary fold) de-epithelialized flap with a tapering, oblique excision of the glandular tissue to the muscle fascia.[8]

• Another technique was described by Abramson; it involves "a dermal pedicle 9 cm wide at the base that extends superiorly to a point halfway between the inframammary fold and the nipple."[9] This pedicle then could be trimmed intraoperatively to give the desired nipple projection. A superiorly based dermoglandular flap can also be created by deepithelializing (as opposed to excising) the tissue between the vertical markings of the Wise pattern that is invaginated when the vertical skin edges are reapproximated. An excellent illustration accompanies Abramson's article.[9]

• McKissock suggested "stair casing" the incision and retaining glandular tissue along the excision line to help with providing breast tissue for projection.[1]

  Resection by "staircasing" the breast tissue or beveling away from the skin edges preserves breast tissue that may help with improving nipple projections. Image used with permission from McKissock, Paul K. Color Atlas of Mammaplasty. Thieme Publishers. 1991:47-78.

• Fredricks suggested a keel-shaped excision of the keyhole to prevent excess flattening.[10] Closure is accomplished by liberal irrigation and meticulous hemostasis followed by placement of a drain that is brought out laterally and secured.

• Matarasso has questioned the need for drains.[11] He compared the complication rate of 50 patients without drains to statistics from previous studies. His conclusion was that routine drainage was unnecessary and should be reconsidered. However, in the author's experience, drains have not increased morbidity. As drainage can be considerable, the author prefers to use drains.

Traction on the lateral flap provides most of the coverage of the resultant defect. This allows flattening of the lateral pole and diminishes the need for the medial flap to be pulled excessively. Pulling the medial flap laterally in excess results in breasts appearing like "aviator glasses" and lacking the medial fullness of an unoperated breast.

Key sutures are placed using heavy absorbable sutures to reapproximate the skin edges (breast pillars if applicable), then more interrupted, buried, absorbable sutures are placed in the vertical and inframammary fold dermis, burying the knots.

Closure of the skin is accomplished as per the preference of the surgeon. The nipple-graft sites are prepared by invaginating any protrusions or dog-ears with 5-0 absorbable suture.

The site is kept moist until the graft is placed on it. The nipple grafts are defatted, and then placed into the graft sites where they are positioned with interrupted 5-0 Prolene sutures to stretch out the graft. A running peripheral 5-0 Prolene suture is used to approximate skin edges.

The graft is covered with a bolster dressing fashioned from Xeroform gauze and oil-moistened cotton balls.

The bolster dressing is secured with widely placed 3-0 Prolene horizontal mattress sutures, which are left in place for at least 10 days.

Dressing is then positioned per the surgeon's preference, and the breast is placed into a light brassiere.

The dressings are left in place if there are no problems.

Drains are removed in 3-4 days if the drainage is less than 30 mL/day. Vertical and fold dressings are changed in the same visit and continued until drainage ceases.

Vertical sutures are removed after 1 week, and the fold sutures are removed 11-14 days postoperatively. The bolster dressing is also removed at this time. McKissock suggests removal of the bolster dressing after a 2-week period.[1]

Breasts may get wet during showers after the bolster dressings have been removed. The patient should blot the nipple grafts dry until certainty of take.

The nipple tip is likely to necrose and slough. Topical ointment and gauze is used to dress the nipple until it has healed.

The patient is seen after 3-4 days for removal of the drain and change of dressing. In addition, vertical sutures/staples are removed, and the wound is steri-stripped.

The patient returns again after 10-14 days when the bolster dressing, nipple sutures, and inframammary fold sutures are removed.

She then returns after 3-4 weeks and again after 2 months assuming no complications exist. Photographs are taken at the last visit.

A baseline mammogram is considered for the following reasons:

• Strong family history of breast cancer

• Suggestive lesions in preoperative mammograms

• Patient requires one because it is time according to American Cancer Society guidelines

She should continue with breast self-examinations on a regular basis.

Patients who undergo surgery of the breast are prone to the complications that accompany any operation. This includes pain, infection, bleeding, seroma, pulmonary emboli, thrombophlebitis, allergy to topical antiseptics, and tape irritation.

Additional possible complications include asymmetry, contour irregularities, skin or nipple loss, inability to breastfeed, nipple numbness, skin flap necrosis, high-riding nipple (aka bottoming out), over or under resection, wound complications, and poor scarring.

The patient's desired breast size and appearance may not be met with this procedure. Significant weight loss following reduction surgery may lead to diminished breast size to where an augmentation could be considered.

A retrospective study by Hillam et al indicated that smoking increases the chance of wound complications in reduction mammaplasty, with the odds ratio reaching 1.72. The report utilized data from over 13,000 patients.[12]

A study by Simpson et al using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) found that out of 16,812 cases of primary reduction mammaplasty (with cancer-related procedures excluded), the overall complication rate was 6.2%, with the major complication rate being 3.0%. Complication risk factors included diabetes, bleeding disorder, hypertension, obesity, smoking, steroid use, and prolonged operative time. Body contouring, but not liposuction, performed concurrently with reduction was found to increase the major complication risk.[13]

Another study of complications in reduction mammaplasty, by Young et al, found that out of 9110 patients who underwent bilateral reduction mammaplasty, the cumulative complication rate was 11.65% in those over age 60 years, compared with 8.89% in patients under age 60 years. The report, which also used the ACS NSQIP, indicated that the risk for cerebrovascular accidents, myocardial infarction, and readmission was greater in the older group. The report also found that smoking significantly increased the risk for superficial surgical site infection and deep space infection, while diabetes significantly raised the likelihood of patient readmission, with neither risk factor being associated with age.[14]

Most patients polled postoperatively express considerable relief from their symptoms and satisfaction with the end result.

Many are encouraged to start weight loss programs, which are easier to participate in because of a patient's increased mobility.

There is less risk for "bottoming out" following this technique and better long-term preservation of the desired breast shape.

Full, unrestricted activities may be resumed one month after surgery with the use of a good quality sports bra (assuming there are no surgical complications).

A study by Beraldo et al suggested that in women with breast hypertrophy, breast reduction surgery can improve sexual function and relieve depression. The study included 56 women with breast hypertrophy, 29 of whom underwent breast reduction and the rest of whom did not. Using the Female Sexual Function Index and Beck Depression Inventory, the investigators found that at 3- and 6-month follow-up, the breast reduction patients reported better sexual function, while at 6-month follow-up, they demonstrated better depression scores.[15]

In a study of reduction mammoplasty in patients with macromastia, Talwar et al found that clinical, patient-reported, and aesthetic outcomes were superior when the surgery employed extended pedicles rather than free nipple grafts. Patients in the report had a reduction weight of over 1500 g per breast or a sternal notch-to-nipple distance of 40 cm or more. Satisfaction, as measured with the postoperative BREAST-Q scores, was greater with the use of extended pedicles, with aesthetic outcomes judged significantly better with the pedicle technique than with free nipple grafts, in 14 matched pairs of patients. The investigators also determined that the incidence of postoperative cellulitis in the nipple-graft patients was 23%, versus 0% in the extended-pedicle group, but the two cohorts did not differ with regard to other medical or surgical complications.[16]

Continuous efforts are being made to find methods, such as the vertical mammaplasty by Lejour, that decrease scars yet produce predictable results.

The vertical pattern has been applied to nipple grafting techniques of breast reduction with satisfactory outcomes.

Theoretically, this technique removes most, if not all of the ductal tissue and should decrease risks for ductal carcinomas.