Niri Niranjan, Consultant Plastic and Reconstructive Surgeon, St Andrews Centre for Burns and Plastics, Essex, UK

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The techniques of reduction mammoplasty have evolved over many centuries with particular refinements being made over the last 100 years. This section will give a brief glimpse of the historical evolution of the technique and the different pedicles used and described in the following tables. This is followed by a guidance on how I choose my technique and finally there are videos on inferior pedicle breast reduction.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reduction mammoplasty would incorporate a pedicle to sustain the vascularity of the Nipple areolar complex; unless free nipple grafting is contemplated. Over centuries the pedicles have evolved with every part of the breast mound serving as a pedicle in the various techniques described. Table 2 lists some of the common descriptions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood supply

 

Understanding the blood supply remains paramount to a successful reduction technique as all the pedicles described serve to retain the blood supply through one or more of the vessels. The key vessels supplying the breast include the internal mammary artery, lateral thoracic artery, thoracodorsal and antero-lateral inter-coastal perforators. There is extensive collateral circulation through these vessels both to the gland and the skin thereby making the different techniques of reduction feasible.

 

Nerve supply to the Nipple areolar complex

 

Innervation to the NAC is complex with extensive variability. Anterior ramus of the 4th lateral inter-coastal nerve is considered to be the most reliant nerve supplying the NAC.

 

Indications

 

• Hypertrophy

• Symmetrisation

• Mastopexy

 

Matchmaking- Options available for reduction and when to use what ?

 

It is important to have a gauge of the volume of reduction required which can be crudely worked out from the chest circumference and the cup size. Table 3 below gives a guide to approximate weight of tissue per cup size in some common chest circumferences (Rule of thumb for size and cup; Regnault-1984)

 

 

 

 

 

 

 

 

 

 

It is important to bear in mind that the breast volume can be reduced by a number of methods. Table 4 below gives list of non-wise pattern techniques along with their proponents.

 

 

 

 

 

 

 

 

 

 

 

 

 

In planning the reduction, Niri Niranjan uses a matchmaking concept where in the factors from history and the clinical examination including the estimated volume of reduction is taken into consideration to plan the technique of reduction. Table 5 represents the matchmaking concept

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Thus taking into consideration the 5 key factors a decision is made on the nature of the reduction technique required. If it is deemed appropriate to undertake a wise pattern based reduction technique- An inferior pedicle based reduction can be undertaken as follows.

 

Marking the patient- Inferior pedicle breast reduction

 

This is undertaken prior to the surgery on the ward, on the day of the procedure. Video 1 gives the steps of the marking pre-operatively.

 

Videos

 

Preoperative Marking Video

 

 

 

 

 

 

 

 

 

 

 

 

 

Operative Marking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

De-Epithelialization

 

 

 

 

 

 

 

 

 

 

 

 

 

Resection and Closure

 

 

 

 

 

 

 

 

 

 

 

 

 

Dressings and post-op care

 

Drains are inserted in both breasts and are removed 24/48 hours later depending on the drainage.

 

Following the operation, sutures are protected with steri-strips and the shape of the breast is maintained by applying micro-foam dressing, which if possible is left for a week. Patient is encouraged to wear a sports bra with the cup of the bra maintaining the shape of the breast for next 6/52.

 

Complications

 

Inevitable:

 

• Scar (Hypertrophic/Keloid)

 

Preventable:

 

• Bleeding

• Infection

• asymmetry-requiring adjustment surgery

 

Unpredictable :

 

• Loss of sensation in the nipple, Partial or complete loss of nipple

• Skin and/or fat necrosis

• Wound breakdown

• Asymmetrical breast, around 10% of patients require further surgery

 

Other rare complications

 

• Necrotising fasciitis or pyoderma gangrenosum leading to septicaemia

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