4411-4415-Surgical Therapy of Breast Hypertrophy

European Review for Medical and Pharmacological Sciences 2016; 20: 4411-4415 Surgical therapy of breast hypertrophy: a comparison of complications and satisfaction rate in large and small superior pedicle custom-made reduction mammaplasty P. FINO, G. DI TARANTO, M. TOSCANI, N. SCUDERI Department of Plastic, Reconstructive and Aesthetic Surgery, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy Abstract. – OBJECTIVE: The reduction mam- tomatic breast hypertrophy. Large ptotic breasts maplasty is indicated for patients with sympto- can become troublesome for patients, leading to matic breast hypertrophy. Although surgery is mastalgia, ulceration of the skin on the mamma- considered the gold standard treatment, it is ry crease, postural problems, and related back still debated which is the complication rate and pain, strongly affecting social life of the patients2. whether or not there is an increased complication rate with increased tissue resection per bre- These patients can benefit greatly from a reduc- ast. The main objective of this retrospective stu- tion in breast size, as most symptoms are relieved dy was to determine whether the rates of compli- by reduction mammaplasty. Goals of reduction cations are higher in large reductions (≥2000 g mammaplasty are to improve physical, emotional per breast) as compared with smaller reductions and psychosocial discomforts, to restore a coni- (≤1999 g per breast) using the superior pedicle cal-shaped breast stable over time, maintaining custom-made technique. scars as short as possible3,4. PATIENTS AND METHODS: A retrospective study of 90 consecutive operated patients was When performing breast reduction surgery, performed. All the patients underwent a bilateral it is very important to preserve the blood supply breast reduction for macromastia. 43 patients of tissues as well as sensitivity, especially of the had a reduction of 1999 g or less and 47 patients nipple-areolar complex (NAC)2,5. In 1922, Thorek had a reduction of 2000 g or more. described standard free nipple grafting reduction RESULTS: There were no statistically significant mammaplasty in gigantomastia6. Although this differences in the rates of nipple necrosis, hematoma, seroma, wound dehiscence, wound infection, technique remains simple and reliable, it can pro- loss or reduction of nipple sensation, and a patho- duce a non-aesthetic breast and nipple with poor logic scar between the large and small resections. projection and no sensitivity. It has gradually CONCLUSIONS: The large reduction patients been superseded by dermoglandular flap tech- pointed higher mean satisfaction rate than the niques and several pedicle techniques have been small reduction patients. The superior pedicle cus- described in breast reduction surgery2,7. tom-made technique is a safe method of breast However, like all surgical procedures, these reduction regardless of the degree of parenchymal resection, achieving a successful aesthetic out- new techniques are not complications free. Re- come with minimal scarring and high satisfaction ported complication rates vary widely, and there rate for both small and large breast reduction. is controversy as to whether or not there is an increased complication rate with increased tissue Key Words resection per breast8,9. The main objective of this Breast reduction, Gigantomastia, Germal flap, Cus- retrospective study was to determine whether tom-made technique. the rates of complications are higher in large reductions (≥ 2000 g per breast) as compared with smaller reductions (≤ 1999 g per breast) using Introduction the superior pedicle custom-made technique. We used the crossover point between small and large Reduction mammaplasty is one of the most com- reductions at 2000 g of tissue per breast, follow- mon procedures performed by plastic surgeons1. ing a simple cut-off method, as already described The reduction is indicated for patients with symp- by Chang et al8 and O’Grady et al9. Corresponding Author: Pasquale Fino, MD, e-mail: [email protected] 4411 P. Fino, G. Di Taranto, M. Toscani, N. Scuderi Patients and Methods skin was preoperatively evaluated with a pinch test to allow appropriate skin resection, result- Patients ing in a rhomboidal draw. After local anesthe- sia with adrenalin 1:200.000 infiltration and a A retrospective chart review of 90 consecutive careful depithelization of the periareolar area, patients performed between September 2010 and dermal incisions were made up to the pectoralis June 2015 was considered. All the patients under- muscle fascia through glandular-adipose tissue. went bilateral breast reductions for macromastia Saving the dermal flap previously depithelized, at our facilities. Smokers, patients with diabetes glandular resection was performed according to mellitus or those who had previously undergone the traditional inverted V shape and a pyrami- breast surgery or a balancing procedure for can- dal glandular portion was removed inferiorly up cer were excluded because of the possible bias in to the mammary crease and superiorly approxi- the results analysis. mately 1 cm below the dermal flap. Medial and All the procedures were performed by the lateral edges of the inverted V were rejoined and same surgical team. The entire protocol was the dermal flap was then fixed with 3 interrupt- approved by the Ethics Committee of Sapien- ed 2/0 resorbable stitches to the new mamma- za, University of Rome. Age, height, weight (in ry crease, to hold the inferior pole of the new kg), body mass index (in kg per square meter) breast, preventing a recurrence of ptosis such (BMI), resection weight per breast (in g) and as very often happens with vertical scar tech- midclavicular point-nipple distance were re- niques. Skin resection was made after glandular corded (Figure 1). resection to minimize the tension of the sutures. A round block was performed around the areola, followed by closure of the vertical scar, which Surgical Technique was converted to an L-shape scar only when the skin excess was too redundant in the lower pole, Keeping in mind the anatomical variability of to keep the vertical scar no longer than 6 cm for a each patient, we performed a custom-made re- better aesthetic outcome10. Closed suction drains duction for each patient as previously described were used routinely and were usually removed elsewhere10,11. Preoperative markings were made on the third postoperative day. with the patient in standing position, consider- ing standard marking lines from the middle-cla- vicular point to the nipple. The new nipple was Evaluation of complications positioned at 19-22 cm from the midclavicular and rate satisfaction point, and the new areola was marked at this Data regarding complications rate were re- point with a 3.5-4 cm radius. Therefore, with the corded for each patient of both groups. Occurring patient lying down, we considered 10-11 cm of complications were nipple necrosis, hematoma, distance from the media-sternal to the projection seroma, wound dehiscence, wound infection, loss of the new nipple on the mammary crease. After or reduction of nipple sensation, and pathologic marking of the future vertical scar, the level of scar. Wound infection was diagnosed by a posi- the new inframammary line (IML) was moved 6 tive culture swab. Loss or reduction of nipple was cm below the new areola. The excess periareolar scored by a subjective patient base. Patients were A B C D E Figure 1. Intra- operative images of surgical procedure: A, depithelization of superior pedicled dermal flap; B, glandular resection; C and D, fixation of dermal flap;E , restoration of conical shape. 4412 Surgical therapy of breast hypertrophy Figure 3. Pre- and postoperative photographs demonstrating good mammary reduction, remodeling with short scars, and the recovered girth. distance and tended to be taller and weighed more. Patients of large reduction group were elder than the small reduction one. There were no statistically significant differences in the rates of nipple necrosis, hematoma, Figure 2. Pre- and postoperative photographs demonstrating seroma, wound dehiscence, wound infection, loss good mammary reduction, remodeling with short scars, and the recovered girth. or reduction of nipple sensation, and a pathologic scar between the large and small resections. There was a lower rate of wound dehiscence and wound infection in the smaller resection group asked to score postoperative rate of satisfaction as compared with the large resection group, but on a visual analog scale from 0 to 10. The highest no statistical difference was found. Four patients possible level of satisfaction was 10. The overall were culture-positive for the following organ- evaluated follow-up period was six months. isms: Staphylococcus species, two breasts; Pseu- domonas aeruginosa, one breast; Streptococcus Statistical Analysis pyogenes, one breast. These patients with clinical The statistical significance of the differences and laboratory evidence of infection received ad- between mean values was determined using one- ditional days of antibiotic coverage until negative way analysis of variance (ANOVA) and Fisher’s culture swab. LSD; p ≤ 0.05 was considered significant. Body mass index had no statistically significant effect on the rate of nipple necrosis, hematoma and seroma formation, nipple sensation, Results wound infection or hypertrophic scarring: patients with higher BMI values (≥ 35 kg per square The age distribution of the patients ranged from meter) and lower BMI values (≤ 34.99 kg per 17 to 65 years (mean, 45.7 yrs). The body mass square meter) had similar complication rates. index (BMI) evaluated in the last seven years was However, BMI had a statistically significant 27.4 kg/m 2 on average. 86 breasts (43 patients) effect on wound dehiscence (p ≤ 0.05): a higher had reductions of 1999 g or less and 94 breasts (47 mean BMI predicted wound dehiscence. Differ- patients) had reductions of 2000 g or more. ences were statistically significant when consid- Preoperatively, the range of distance from the ering the overall body mass index, although no midclavicular point to the nipple was 33.4 to 53 significant difference was found when comparing cm.

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