11 Circumvertical Breast Reduction with An Intraoperative-Sequenced Horizontal Component
Two popular approaches exist for breast reduction: the traditional inferior pedicle with Wise pattern incisions and the superomedial vertical reduction mammoplasty with a vertical scar. Vertical reduction techniques have not been widely accepted due to limitations of ability to perform large breast reductions and inability to address the amount of excess skin.
We present circumvertical breast reduction with an intraoperative-sequenced horizontal component technique, which evolved to incorporate the advantageous elements of the inferior pedicle and superomedial pedicle reduction techniques. The purpose of this study was to demonstrate the technique and compare reoperation outcomes of this form of reduction mammoplasty to those reported in the literature.
Methods/Technique:
A retrospective chart analysis was performed of female patients who underwent breast reduction, mastopexy, oncoplastic reconstruction, or revision breast reconstruction using the described technique at our institution. The outcome measure was reoperation at any time point. Pub Med was then queried using the keywords reduction mammoplasty and mastopexy to identify studies with sufficient data to compare reoperation rates to our cohort. Prism 5 (Graph Pad Software, Inc; La Jolla, CA) was used for all statistical analyses.
Preoperatively, the incision pattern is drawn on the breast with the patient in an upright, seated position. The sternal notch, midline, inframammary folds, and breast meridian are marked with an indelible marker. Pitanguy's point is marked for nipple position.
The peri-areolar skin opening, known as the head of the snowman, is then drawn with a superior perimeter 1-2 cm above the central point of the future nipple position. A circular template of varying diameter, ranging from 6-8 cm, is used for this mark. The areola diameter is selected, customarily 38-45 mm.
The vertical marking is centered along the breast meridian and approaches the inframammary fold but stays 2-4cm above the fold.
The nipple is incised at its selected diameter. A 6-10cm superomedial dermoglandular pedicle is designed and deepithelialized. Electrocautery is used to resect a 2-3 cm superolateral crescent of skin and breast tissue within the periareolar skin markings and to resect the inferior-central portion of the breast, also known as the body of the snowman. The nipple is gently transposed superiorly to its new location, and a 3-0 absorbable suture is used to bring the superior tip of the medial vertical skin component and the superior tip of the lateral vertical skin component together. This closes the head of the snowman around the transposed nipple areolar complex. The suture is retracted under tension in a cephalad direction while the medial and lateral breast pillars are approximated. The length of the vertical limb is determined depending on many variables to match the opposite breast and is now approximated. Vertical limb lengths typically range from 5-9 cm with 7-8 cm being most common. Next in sequence, the horizontal component is designed.
To determine the marking for the horizontal component, the suture-on-a-clamp at the superior end of the vertical limb (also at the bottom of the areola) is retracted inferiorly. When this is done, a horizontal crease will appear in the skin at the bottom of the newly shaped breast. This is the superior edge of the horizontal component, and it is marked. This mark and the native inframammary fold mark are then connected to points medially and laterally, creating the fusiform horizontal component that will be resected. These marks can be lengthened or shortened to control the length of the horizontal component.
The remainder of the inferior vertical breast pillars is closed. The inferior portion of the vertical limb is brought slightly medially and sutured to the inframammary fold without tension. The nipple areolar complex is matured along the breast meridian within the periareolar skin circle, and the vertical and horizontal skin components are closed. Tailor-tacking for this procedure is not necessary. Sitting the patient up is rarely necessary and not routinely performed
Results/Complications:
From 2006 to 2011, 1694 circumvertical breast reductions with an intraoperative-sequenced horizontal component were performed on 1,304 patients (reduction n=1019, mastopexy n=398, oncoplastic reconstruction n=44, revision breast reconstruction n=233). The average combined weight removed was 1829 ± 123.2 grams for bilateral reductions (minimum 167g, maximum 5700g). Forty seven breasts (2.8%) require reoperation for correction of asymmetry, drainage of hematomas / seromas, and minor wound dehiscence.
Pub Med search yielded 25 studies from 1996-2011 for analysis. These studies included 3,289 operations. Of these operations, 176 (5.4%) required revision. The revision rates in these studies ranged from 0% to 22%. Using χ2 analysis, our technique demonstrated a significant improvement in need for revision in the literature compared to this technique (p < .0001, odds ratio 1.929 and likelihood ratio 1.613).
Conclusion:
This technique is reliable, gives predictable results, and can also be used in the setting of significant macromastia and/or breast ptosis with better revision rates than presently reported in the literature.
