- Breast Reduction Skin Excision Patterns
- Wise Pattern Breast Reduction Techniques
- Vertical Breast Reduction Techniques
- Special Situations
Breast Reduction Skin Excision Patterns
Wise Pattern Breast ReductionThe Wise pattern places incisions along the inframammary fold of the breast, a vertical incision from the fold up to the areola border, and an incision around the border of the areola. The resulting incision looks like an inverted –“T” or an anchor after final closure. This pattern is usually employed for patients with very large breasts, but can be used for almost any reduction volume. In addition, this technique is commonly used when the patient has poor skin quality and the breast is very loose, or when the NAC has to be raised a significant length in order for the breast to have a youthful appearance.
Vertical Breast ReductionThe vertical breast reduction eliminates the inframammary incision. Dr. Wallach will commonly employ a vertical breast reduction technique (usually a modified LeJour technique) that minimizes the amount of scarring on the breast using a “lollipop-type” pattern that encompasses a circular incision around the areola with a lower breast vertical incision. This technique is often used for smaller breast reductions, when the patient’s skin quality is good, and the NAC does not have to be raised a significant length.
Horizontal incision techniqueThis is a technique that employs an inframammary incision and an incision only around the areola. There is no vertical incision component from areola border to the breast fold that is seen with the Wise pattern or vertical pattern. This is performed using an inferior pedicle technique, and can be used for larger breast reductions and long pedicle lengths. A disadvantage of this technique is that the breast can look a bit “boxy.
Wise Pattern Breast Reduction TechniquesThere are numerous named reduction techniques employing the Wise skin pattern excision based upon the orientation of the blood supply feeding the pedicle to the nipple areola complex (NAC). The three most common are:
Inferior PedicleThe inferior pedicle technique is probably the most popular one used today because it is considered the most versatile. Some studies suggest that patients undergoing this technique have the best post-surgical sensation of the NAC and also have the best chance to adequately breast feed.
Superior PedicleIs a reasonable approach for patients who only need the NAC moved a short distance. It is good for smaller reductions than what can be achieved with the inferior pedicle technique.
Superomedial PedicleIs a technique that employs a pedicle based superomedially on the chest. It can be used for large reductions and in those with low hanging breasts.
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Other TechniquesThere are other pedicle designs including those using the central mound, the lateral pedicle, the medial pedicle, various bipedicle forms, and the supero-lateral pedicle.
Vertical Breast Reduction TechniquesThere are many procedures that can incorporate the “lollipop” skin closure. The three most common are:
Superior Pedicle Technique (LeJour)This is a great technique to be used for patients who have moderately good skin quality, require a relatively short pedicle, and do not require a very large reduction. The pedicle is based superiorly and the skin closure results in a lollipop design. Dr. Wallach uses this technique often and has published his modifications on the LeJour technique and has presented it to other surgeons at the Aesthetic Society’s national meeting.
Superomedial Technqiue (Hall-Findley)This is a very versatile technique that can be used for larger reductions than the LeJour technique because the pedicle is turned from the superomedial aspect and more tissue laterally and superiorly can be removed. The closure is similar to the Lejour in that the resulting closure looks like a “lollipop.”
SPAIR Technique (Short-Scar Periareolar Inferior Pedicle Reduction) (Hammond)This is different than the superior pedicle or superomedial techniques described above because the pedicle is inferiorly based. Similar to the inferior pedicle technique using the Wise pattern skin closure, more tissue can be removed superiorly than with the above techniques described.
Massive Weight Loss PatientsMost massive weight loss patients are often not good candidates for a vertical breast reduction technique because they often have poor skin quality and the skin envelope is very loose. For these patients, a Wise pattern skin incision pattern will often achieve the desired result. For massive weight loss patients, Dr. Wallach has used both types of skin incision designs to achieve nice results for his patients.
Liposuction Only Breast ReductionSome plastic surgeons perform breast reductions using only liposuction. This limits the use of breast incisions. However in the majority of patients, it will not adequately “lift” the breast or reduce the skin envelope. Thus, the breast will potentially be looser after the procedure. If the breast is primarily fatty tissue, then liposuction can be successful in removing the excess breast weight, but this technique will usually not consistently improve the aesthetic appearance of the breast. If there is significant ptosis (sagging) and the NAC is low on the breast mound, it will not provide the lift needed to create a more youthful look.
Free Nipple Graft TechniqueThe free nipple graft technique is used for patients that have extremely large breasts and whose NAC are very low on the chest. When the potential pedicle length is too long, there is a risk that the NAC will not survive. Therefore, a free nipple graft technique is an option. A pedicle of tissue is used to restore an aesthetic breast mound. The NAC is removed and replaced on the chest skin at an aesthetically pleasing position as a free graft. This technique will eliminate the ability to breast feed, and may result in partial or incomplete NAC survival. It may also lead to hypopigmentation of the NAC. In general, breast reduction surgery takes between two and four hours to complete with a recuperation time of one to two weeks. Often patients will have a drain in each breast that is commonly removed a few days after surgery. Patients wear a support bra without an under-wire or a sports type bra for about three to six weeks before they can go back into an under-wire bra. Dr. Wallach recommends that patients avoid aerobic type exercise for at least three weeks and strenuous exercise for at least six weeks after surgery. Dr. Wallach has presented and published papers on breast reduction and has presented his experience and techniques to other plastic surgeons. For many years, Dr. Wallach has given an instructional course to fellow plastic surgeons on his preferred techniques at the American Society of Aesthetic Plastic Surgery (ASAPS) national meeting.
In many ways a breast reduction and breast lift are similar. A breast reduction reduces the overall volume of the breast parenchyma, the excess skin is excised to drape over the gland, and the nipple areola complex is lifted into a more aesthetic position. A mastopexy or breast lift is similar in that the gland is lifted and often parenchymal sutures are used to shape the breast, the skin is then draped over the gland, the excess skin is removed, and the nipple areola complex is raised to a more aesthetically pleasing position. While some tissue may be removed during a breast lift, it is often minimal in most cases. In many ways, the amount of tissue removed is really the biggest difference. There are many different techniques that are used to perform these procedures. The skin can be excised in an inverted “T” fashion or what is sometimes referred to as an anchor incision. This means that there will be stitches around the areola, vertically from the base of the areola to the breast fold, and also along the inframammary fold in a transverse fashion. A common alternative is a lollipop incision pattern in which there are only stitches around the border of the areola and vertically from the base of the areola to the breast fold, thus eliminating the inframammary incision. The breast parenchymal tissue can be treated using various tissue pedicles most commonly using an inferior pattern, but this can also be vertically, superomedial, or superolateral. Modifications of the breast lift procedures are sometimes performed when a patient desires breast implants as well. A circumareola lift can sometimes be offered when only the nipple has to be raised a short distance.
In order to say if a patient is a good candidate for a breast reduction, she would have to be seen in person. An examination in person will allow the surgeon to evaluate any asymmetries, and appreciate the weight of the breasts and possible volume that can be removed from each breast. Obviously, a breast reduction is performed on a patient with very large breasts that wants them to be smaller. Commonly, the patient has symptoms of bra strap grooving, neck or back pain, and potentially has rashes underneath the breasts. Symptoms like back pain or neck pain may not improve with a reduction, but there are scientific studies suggesting that it does help many women who have breast reductions. There are many different techniques that can be employed to perform a breast reduction. The skin pattern design often employs the use of an inverted “T” or anchor type incision, or a lollipop type of incision. Various parenchymal excision patterns can be used. They are named by the orientation of the blood supply feeding the nipple areola complex. The design of the skin pattern and the choice of the pedicle will vary from patient to patient based upon their anatomy and the surgeon’s experience.
The choice to undergo breast reduction surgery is totally up to the patient. If the patient has very large breasts that she desires to reduce whether it is strictly for cosmetic reasons, or because she has symptoms such as bra strap grooving, neck or back pain, or rashes is a personal choice. Aesthetically, the breasts can be made smaller by removing the excess tissue and skin to alleviate the excess weight and pressure that heavy breasts can cause, as well improve the position of the nipple and in most cases reducing the overall diameter of the areola as well. When to have a breast reduction is another issue. Again it is a personal choice. Some women undergo the surgery in their late teens and early 20’s before having children, while others undergo the surgery later in life. There is no defined best time in life to have it performed. Patients choose when it fits into their life.
A breast reduction is often performed as an outpatient. This procedure takes about 2-4 hours to complete. Patients often go home wearing light dressings that are covered by a surgical bra. Many surgeons place drains during the procedure which are commonly removed within a week or so after surgery depending upon the amount of drainage. Most patients will be able to go back to light duty within 5-7 days after the procedure, provided that they are healing well and have had no complications. Many patients will be able to go back to light aerobic activity within about 3-4 weeks. Heavy lifting and strenuous workouts can be started about 6-8 weeks after surgery if all goes well. It is always best to check with your surgeon as you are healing to see when it is right for you.
Patients with large breasts may have back pain. Back pain can be caused by many different things. Back pain may improve with a breast reduction. Intuitively it makes sense, because surgery will reduce the overall weight of the breasts, thus putting less stress on the back. There are numerous studies in the literature that support this concept. I do tell patients that back pain can occur for many different reasons and that symptoms may not improve after breast reduction. Fortunately, many patients do have improvement of back pain after undergoing a breast reduction.