Breast reduction


Reduction mammoplasty is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the patient's body, the critical corrective consideration is the tissue viability of the nipple–areola complex, to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the patient's self-image, and of the patient's mental health.
In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to mastopexy.

Presentation

The patient with macromastia presents heavy, enlarged breasts that sag and cause chronic pains to the head, neck, shoulders, and back; an oversized bust also causes secondary health problems, such as poor blood circulation, impaired breathing ; chafing of the skin of the chest and the lower breast ; brassière-strap indentations to the shoulders; and the improper fit of clothes.
In the patient affected by gigantomastia, the average breast-volume reduction diminished the oversized bust by three brassière cup-sizes. The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations imposed by a bodily disproportionate bust; thereby, it improves a patient's physical and mental health. Afterwards, the patient's ability to comfortably perform physical activities previously impeded by oversized breasts improves emotional health by reducing anxiety and lessening psychological depression.

Medical history

The medical history records the patient's age, the number of children the patient has borne, the patient's breast-feeding practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information are the patient's history of tobacco smoking and concomitant diseases, breast-surgery and breast-disease histories, family history of breast cancer, and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness.
The physical examination records and establishes the accurate measures of the patient's body mass index, vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of breast ptosis, the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the nipple–areola complex, and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight, kyphosis, skin irritation, and skin rash affecting the breast crease.

Cause

Large breasts are usually developed during thelarche, but they can also develop postpartum, after gaining weight, at menopause, and at any age. Macromastia usually develops in consequence to the hypertrophy of adipose fat, rather than to milk-gland hypertrophy. Moreover, many are genetically predisposed to developing large breasts, the size and weight of which are often increased, either by pregnancy, by weight gain, or by both conditions; there also exist iatrogenic conditions such as post–mastectomy and post–lumpectomy asymmetry. Nonetheless, it is statistically rare for a young person to experience juvenile mammary hypertrophy that results in massive, oversized breasts, and recurrent breast hypertrophy.
The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the overdevelopment of the milk glands or of the adipose tissue, or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild to the moderate to the severe. Macromastia can be manifested either as a unilateral condition or as a bilateral condition that can occur in combination with sagging, breast ptosis that is determined by the degree to which the nipple has descended below the inframammary fold.

Therapeutic approaches

Medical

Breast hypertrophy does not respond to medical therapy, but a weight-reduction regimen for the certain patients can alleviate some of the excessive size and volume of abnormally enlarged breasts. Physical therapy provides some relief for neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chafing, infection, and bleeding.

Surgical

The traditional surgical techniques for breast reduction remodel the breast mound using a skin and glandular pedicle, and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar – around the NAC, where the dark-to-light skin-color transition hides the surgical scar.

Anatomy of the breast

The procedure

A reduction mammoplasty to re-size enlarged breasts and to correct breast ptosis resects excess tissues, overstretched suspensory ligaments, and transposes the NAC higher upon the breast hemisphere. During puberty, the breast grows in consequence to the influences of the hormones estrogen and progesterone; as a mammary gland, the breast is composed of lobules of glandular tissue, each of which is drained by a lactiferous duct that empties to the nipple. Most of the volume and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules, except during pregnancy and lactation, when breast milk constitutes most of the breast volume.

Composition

Surgically, the breast is an apocrine gland overlaying the chest – attached at the nipple and suspended with ligaments from the chest – which is integral to the skin, the body integument of the individual. The dimensions and weight of the breasts vary with age and habitus ; hence, small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750–1,000 gm. Anatomically, the breast topography and the hemispheric locale of the NAC are particular to each individual; thus, the desirable, average measurements are a 21–23 cm sternal distance, and a 5–7 cm inferior-limb distance.

Blood supply and innervation

The arterial blood supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery, the lateral thoracic artery, and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries. Drainage of venous blood from the breast is by the superficial vein system under the dermis, and by the deep vein system parallel to the artery system. The primary lymph drainage system is the retromammary lymph plexus in the pectoral fascia. Sensation in the breast is established by the peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerves, and thoracic spinal nerve 4 innervates and supplies sensation to the NAC.

Mechanical structures of the breast

In realizing the breast-reduction corrections, the plastic surgeon takes anatomic and histologic account of the biomechanical, load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility.
  1. Rib cage. The 2nd, 3rd, 4th, 5th, and 6th ribs of the thoracic cage are the structural supports for the mammary glands.
  2. Chest muscles. The breasts overlay the pectoralis major muscle, the pectoralis minor muscle, and the intercostal muscles, and can extend to and cover a portion of the anterior serratus muscle, and to the rectus abdominis muscle. The body posture of the patient exerts physical stresses upon the pectoralis major muscles and the pectoralis minor muscles, which cause the weight of the breasts to induce static and dynamic shear forces, compression forces, and tension forces.
  3. Pectoralis fascia. The pectoralis major muscle is covered with a thin superficial membrane, the pectoral fascia, which has many prolongations intercalated among its fasciculi ; at the midline, it is attached to the front of the sternum, above it is attached to the clavicle, while laterally and below, it is continuous with the fascia.
  4. Suspensory ligaments. The subcutaneous layer of adipose tissue in the breast is traversed with thin suspensory ligaments that extend obliquely to the skin surface, and from the skin to the deep pectoral fascia. The structural stability provided by the Cooper's ligaments derives from its closely packed bundles of collagen fibers oriented in parallel; the principal, ligament-component cell is the fibroblast, interspersed throughout the parallel collagen-fiber bundles of the shoulder, axilla, and thorax ligaments.
  5. Glandular tissue. As a mammary gland, the breast comprises lobules and the lactiferous ducts, which widen to form an ampulla at the nipple.
  6. Adipose tissue. The fat tissue of the breast is composed of lipidic fluid that is 90–99 per cent triglycerides, free fatty acids, diglycerides, cholesterol phospholipids, and minute quantities of cholesterol esters, and monoglycerides; the other components are water and protein.
  7. Fatty tissue. In biology, adipose tissue, or body fat, fat depot, or just fat, is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts. Its main role is to store energy in the form of lipids, although it also cushions and insulates the body. Far from hormonally inert, adipose tissue has in recent years been recognized as a major endocrine organ, as it produces hormones such as leptin, resistin, and the cytokine TNFα. Moreover, adipose tissue can affect other organ systems of the body and may lead to disease. Obesity or being overweight in humans and most animals does not depend on body weight but on the amount of body fat – to be specific, adipose tissue. Two types of adipose tissue exist: white adipose tissue and brown adipose tissue. The formation of adipose tissue appears to be controlled in part by the adipose gene. Adipose tissue was first identified by the Swiss naturalist Conrad Gessner in 1551.
  8. The skin envelope. The breast skin is in three layers: the epidermis, the dermis, and the hypodermis. The epidermis is 50–100 μm thick, and is composed of a stratum corneum of flat keratin cells, that is 10–20 μm thick; it protects the underlying viable epidermis, which is composed of keratinizing epithelial cells. The dermis is mostly collagen and elastin fibers embedded to a viscous water and glycoprotein medium. The fibers of the upper dermis are thinner than the fibers of the deep dermis, thus the skin envelope is 1–3 mm thick. The thickness of the hypodermis varies between individuals, and between body parts. The skin of the nipple and areola is further composed of a modified and specialized myoepithelium that is responsible for contraction in response to stimuli.