Breast Reduction, Nipple Grafting Treatment & Management

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.

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• 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.