PR52 BREAST REDUCTION
Authors: Codner M. A. , Weinfeld A. B. 
Published: April 2007

Introduction  Breast reduction is one of the most gratifying procedures preformed by plastic surgeons. While moderate sized breast reduction is often considered an aesthetic surgery procedure by third party payers, all patients ultimately care about the aesthetic outcome. While the medical indications for breast reduction include neck pain, shoulder pain, back pain, and intertrigo, patients, especially those with less pronounced macromastia, are focused on breast‐body disproportion, asymmetry, and excessive ptosis. The wise surgeon treats breast reduction as an aesthetic surgery case and focuses not only on the functional issues but on the aesthetic shape contour of the resultant breast. The Wise pattern/central mound technique constantly meets the aesthetic demands of reduction patients.

Technique/Methods  The predominant method of breast reduction in my practice is a central mound parenchymal dissection with hand shaping of the breast mound independent of predrawn patterns. This method is preferred because it preserves the ability to breast‐feed, can be free‐hand optimized on the table, has a robust blood supply, permits the correction of late bottoming‐out with simple skin tightening, and can be performed independent of sternal notch to nipple distance. The limitation of this technique is the inability to reduce most breasts smaller than a C or large B. The markings are made with the patient in an upright position. The new NAC position is determined with a bimanual palpation at the IMF. The remainder of the markings are made by an inverted T‐shape to elevate the skin and 3–4 cm flaps off the central breast mound. The inferior vertical markings are located by the lateral/medial displacement method. The NAC is incised as a circle with a diameter of 42 mm. The central mound is then sculpted from the surrounding parenchyma. The superior tissue is raised as a flap of progressively increased thickness to preserve superior fullness and is elevated off the pectoralis major muscle to the clavicle. The majority of the parenchymal resection occurs in the infero‐lateral region. The central mound parynchema and nipple are shaped like a living breast implant and sutured to the chest wall with 3‐0 vicryl. Following the previously planned excision of skin, staples are used to close the wounds. Tailor taking staples are then used to optimize shape and contour with patient is the sitting position. The distance from the inferior areaola to the inframammary incision is generally 6–7 cm. The lateral infra‐axillary area is reduced with SAL if indicated. The wounds are then closed in multiple layers. Drains are not used routinely.

Results  The Central mound technique was performed in 162 patients over a 12 year period. Other techniques used much less frequently include: superior medial pedicles, vertical reduction, and free nipple grafts. The average age of the patients was 48 years. The average pre‐operative bra size was full C or small D cup. The average reduction weight was 500 gm per side. The average time per procedure was 3 hours and the average blood loss was 150 cc with no cases requiring transfusion. The most common acute complication was hematoma which occurred in less than 2% of patients. Subacute complications included: temporary loss of nipple sensation, delayed wound healing, and seroma requiring drainage. The most common long‐term complications were: failure to produce adequate reduction, asymmetry, and permanent hypesthesia of the NAC. Total loss of nipple sensation was not observed. 5% of the patients underwent revision surgery most commonly for scar revision or bottoming out.

Conclusions  Central mound breast reduction reliably produces gratifying results. It is a flexible technique that can be employed in almost any patient desiring breast reduction. Complications are rare and usually minor. The only true limitation is the inability to produce breast smaller than a full B cup. The advantages include the wide application with no breast too large. The Tailor tacking method allows you to individualize the shape and no preconceived patterns are required. Nipple sensibility is preserved as well as the ability to breast feed since the breast ducts are not divided.