Infections are rare and usually occur in the setting of necrotic tissue, which facilitates bacterial growth. Therefore, the application of techniques to avoid tissue necrosis will also reduce the incidence of infections. Hematomas are uncommon, and the risk can be diminished with meticulous hemostasis. Small hematomas may be evacuated through the wound without reoperation; however, larger hematomas require reoperation with evacuation, hemostasis, and drainage. The frequency of seroma formation can be decreased through appropriate dissection techniques. Some surgeons believe the use of cautery increases seroma formation and therefore recommend sharp dissection with judicious use of cautery only for bleeders . Seromas are easily treated with needle aspiration performed at 1-week intervals and are usually resolved with one or two treatments.
Delayed healing is not unique to the vertical reduction technique (Fig. i3.6).Wound-healing complications as high as 20-50 % have been reported with Wise pattern reductions [23-26]. In our experience, most problems with delayed healing and the need for revisions associated with the vertical technique have been related to skin management. This realization prompted the development of the "shape and drape" concept, in which the sequence is to shape the breast, drape the skin, and then resect excess skin. The length and placement of the scar reflects skin management. Skin excision in
Table 13.3. Options for skin excision patterns
Periareolar Vertical Small T J or L
Full "Big T"
the breast should be thought of in three dimensions. Unidimensional skin excision would include circum-areola techniques, while bidimensional skin excision would add a vertical component to the circumareolar method. The combination of a horizontal skin excision with the vertical and circumareola techniques constitutes tridimensional skin excision. Options for skin excision patterns should be thought of as a progression from periareola, to vertical, to small T, to J or L, and, finally, to the full "Big T" (Table 13.3). Possible solutions to skin management problems and delayed wound healing include: avoiding undermining of the medial and lateral flaps; minimizing the redundant skin at the lower end of the vertical incision; avoiding oversuturing, which can cause tissue ischemia; and reinforcing the vertical component and purse string with buried deepithelialized skin. Finally, if need be, do not hesitate to add a short horizontal scar!
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