Breast Reduction /
Lift

Few will disagree that women who undergo breast reduction surgery (reduction mammaplasty) are amongst the most satisfied patients in any plastic surgery practice. Breast reduction may be achieved through open surgery, liposuction, or a combination of techniques.

Numerous studies have validated the improved quality of life that follows this surgery. Backache, neck and shoulder ache, poor posture, bra strap pain, and limited ability to participate in sports are just some of the reasons why women with large breasts seek help.

Currently, there are essentially 3 different surgeries (and variations there-of) available to patients seeking breast reduction. I will concentrate of the 2 "open" surgeries most commonly performed, but it may be useful to know that liposuction (liposuction only breast reduction, LOBR) is occasionally an option for patients requesting moderate breast improvement / volume reduction. Ideal patients for this surgery, are those with little or no ptosis (droop) and breasts that are predominantly composed of fatty tissue(as opposed to breast tissue itself, which is quite fibrous). The effect of liposuction is to decrease breast volume, but little or no lift is achieved. It does however, offer some patients volume reduction with little or no obvious scarring. It may also be of use in patients presenting for a second breast reduction.

Anatomy

A breast is composed of a skin envelope, containing a "parenchyma" composed of varying proportions of fatty tissue and breast / fibrous tissue. As you will read below, some breast reduction techniques focus mainly on altering the skin envelope, and use this to shape the underlying content. More recent techniques have shifted this focus to concentrate on shaping the breast content (parenchyma) and allowing the skin envelope to re-drape. This "philosophy" of moving away from skin tightening and towards effecting change through manipulation of deeper tissues is also found in modern facelift techniques.

Traditional / Long Scar / Wise Keyhole Reduction

Developed in 1956 by Dr Wise, this is probably still the commonest method used for breast reduction today. Like all surgeries, it has some advantages, as well as some disadvantages.

Advantages: It is easy to perform, easy to teach and easy to learn. It involves the application of a "fixed" skin pattern design which results in an "anchor" type of scar on the breast (around the areola, a vertical scar to the breast fold, and a long scar underneath the breast, in the fold, from side to side). It can be used for small reductions, lifts, as well as very large reductions, and the results are generally good.

Disadvantages: The major disadvantage is the extent of the scarring, the quality of which can be good or bad, depending on the patient's skin type, and wound healing ability. In addition, the breasts are occasionally slightly under projected, and tend to "bottom out" with time - this may well be due to the fact that the breast content is not specifically addressed in this surgery, but rather, the shape of the content is determined by the skin pattern design which removes excess skin in both the vertical and horizontal planes.

Short Scar / Vertical Mammaplasty

In an attempt to decrease the scar burden of the Wise pattern reduction, some innovative plastic surgeons (notably from France) looked at ways to perform a breast reduction without the need for a long horizontal scar in the breast crease. This vertical breast reduction has undergone several refinements over the years, and is only more recently gaining wider acceptance. I was fortunate enough to attend a course in San Diego in 2003 given by Dr Elisabeth Hall-Findlay who has refined the technique, and whose method I tend to follow when doing this surgery.

Advantages: Interestingly, the main reason for pursuing this operation (i.e. the shorter scar) is not the major benefit of the surgery. Although the scar is shorter (and the operating time somewhat less) the main advantage appears to be the improved breast projection gained from shaping the parenchyma (content) by using sutures in the breast substance to maintain this projection over time. Conceptually, this is a "breast content shaping" operation, rather than a "skin shaping" operation. In addition, the breast base is narrowed somewhat, and the breast fold is lifted.

Disadvantages: The operation is more difficult to teach, to learn and to perform, as no "fixed pattern" is used - hence some degree of experience is needed. That said, this operation does have a slightly higher minor revision rate (small scar revisions etc) than the Wise pattern , even in the best hands. Another disadvantage is that this technique is not suitable, in my opinion, (and hands!) for larger reductions (over about 500g per side), where I still tend to favour the Wise pattern. Lastly, patients need to be made aware that the breasts will often take a minimum of 3 months to look more natural - they usually have a slightly odd shape early post- op, and the skin of the lower pole is often pleated (much like a curtain pushed together on a rail) initially.

Despite these "trade-offs", the improved projection, lesser scarring, and probable better long term stability of results, make this an attractive option in well selected patients.

Breast Lift / Mastopexy

Mastopexy procedures are indicated for sagging / drooping breasts. There are varying degrees of sag (called breast ptosis) and a multitude of mastopexy options designed to correct these, spanning the full spectrum of aesthetic breast surgery. A mastopexy is done when there has been failure of the breast envelope (skin) to maintain the parenchyma (content) in an aesthetic form, and hence the breast droops, and appears elongated. This may follow weight loss, pregnancy and breast feeding. The breast sags when the content descends, and the nipple complex is sited at or below the level of the breast crease. More often than not, to re-elevate the nipple complex, incisions are placed on the breast mound, which are not dissimilar to those used in a breast reduction (usually the vertical pattern, but occassionally the Wise pattern). Hence scarring on the breast mound itself is a necessary "evil" in mastopexy to accomplish the "lift" and better shape the breast content.

In the mildest form of droop (so-called psuedo-ptosis or false droop) there is deflation of the breast content, along with descent of the bulk of the breast content, but the nipple complex is well sited on the breast mound, above the breast crease. In these cases, one can sometimes simply place a breast implant (in the same way as an augmentation) in the appropriate position and this may be sufficient to give the impression of a breast lift, without resorting to a formal lift.

In those with more significant droop, a formal lift is indicated. This may broadly consist of one of the 3 following options:

1. In the somewhat large breast that has drooped, a small (vertical) breast reduction may be done with good effect. This reduces the volume, unweights the breast and better shapes the breast content around an elevated nipple complex. This is a simple mastopexy. (small breast reduction)

2. In those who want to retain their breast volume (i.e. happy with size in a bra - but not happy with form out of a bra!) we can sometimes offer a mastopexy (breast lift) with an auto-augmentation. This is a somewhat more complex version of # 1, in that the tissue of the lower pole is not resected, but rather "recycled", fashioned in to a pedicled flap (tissue with its own blood supply), and then used to tuck up high on the chest wall towards the cleavage area and sutured in to place. The rest of the procedure is then done as per the usual vertical mastopexy, closing the 2 pillars over the elevated flap. I find this a useful technique in selected patients who want to retain volume, and have sufficient lower pole breast volume to augment the upper pole.

3. In those with an absolute deficiency of breast volume / content, and with sag, one can offer an augmentation mastopexy - adding an implant for the volume (usually beneath the chest muscle - dual plane placement) and doing a breast lift of the remaining tissue. The surgery can be done in one (combined lift + augment)or two stages (either lift or augment first, followed several months later by the other option), the combination of both augmentation and lift in one procedure being notoriously complex and having a fairly high revision rate, but still relatively common in practice.



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Member |  International Society of Aesthetic Plastic Surgery (ISAPS)
Fellow  |  College of Surgeons of South Africa (Plastic Surgery)
Member |  International Member of THE American Society of Plastic Surgeons
Fellow  |  Royal College of Surgeons
Member |  Association of Plastic & Reconstructive Surgeons of SA