Dennis C. Hammond reast reduction offers an opportunity rarely seen in plastic surgery, for not only is there too much volume, there is too much skin. With a sound operative strategy, excellent technique, and a discerning artistic eye, the sculpting of an artistic and stable breast shape can occur every time, and now we can do it with half the scar! What an exciting time to be a plastic surgeon.
Dennis Hammond pattern technique have been thrown into sharper focus. Specifically, the inframammary scar can be problematic in some patients, with the medial and lateral portions of the scar being prone to hypertrophy. Additionally, the postoperative shape change associated with the Wise pattern technique can occasionally spill over from simple postoperative settling into a shape distortion known as "bottoming out." Taken together, these two complications can adversely affect the overall result after breast reduction.
Recent advances in breast reduction technique have attempted to address these problems by reducing the amount of cutaneous scar while preserving aesthetic breast shape. The focus of this chapter will be to describe a reduced scar technique based on an inferior pedicle called the short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty.
Any operative procedure designed to reduce the enlarged breast can be described as having four interrelated components. First, the volume of the breast must be reduced, leaving behind strategically located tissue that will create an aesthetic breast shape. Second, the excessively large skin envelope must be reduced, leaving behind enough skin to cover the reduced breast. Third, a pedicle of tissue must be created that will reliably maintain blood supply to the nipple and areola. Fourth, an aesthetic shape must be created, either passively or with some sort of shaping maneuver. The most common procedure for breast reduction satisfies these requirements by basing the blood supply to the nipple and areola on an inferior pedicle, resecting parenchyma peripherally around the pedicle, using an inverted T-type of skin pattern to manage the excess skin envelope, and passively shaping the breast by closing the flaps around the inferior pedicle and allowing postoperative settling to "shape" the breast. This procedure, also referred to as the "Wise"pattern inferior pedicle breast reduction, has stood the test of time as a reliable and versatile method of breast reduction.
However, with the description of various reduced scar techniques of breast reduction [1-11], the well-documented complications associated with the Wise
The SPAIR mammaplasty bases the blood supply to the nipple and areola on an inferior pedicle with parenchyma being removed from around the periphery of the pedicle in the shape of a horseshoe. Skin is resected in a circumvertical pattern that limits the scar to the central portion of the breast and avoids the more traditional long inframammary scar. By reducing the circumference of the periareolar incision with the vertical skin component, large periareolar patterns can be managed without excessive pleating or distortion of the periareolar closure. In addition, the vertical component tends to produce a coning effect, which enhances the overall shape of the breast. Shaping is accomplished with internal suturing of both the flaps and the pedicle. By combining these surgical maneuvers, a wide variety of breast problems ranging from simple ptosis to severe macro-mastia can be effectively and reliably managed [12-15].
The goal of the marking procedure is to accurately identify the appropriate amount of skin to leave behind that will effectively wrap around the inferior pedicle and assist in shaping the breast. To organize
Fig. 6.2. An 8-cm pedicle is centered on the breast meridian. On either side of the pedicle, a distance of 8 to 10 cm is measured up from the fold, and these two points are communicated in a line that parallels the inframammary fold. This creates a rectangular-shaped segment of skin that defines the limits of the inferior skin envelope
Figs. 6.3,6.4. By drawing the breast first up and out, and then up and in, the breast meridian can be transposed onto the breast at the level of the nipple to identify the medial and lateral points of the pattern this process, the breast is divided into four sections. With the patient upright, the sternal midline, the inframammary fold, and the lateral margin of the breast are marked. The inframammary fold mark is communicated across the midline so that with the breasts in repose the exact location of the fold can be seen without any distortion caused by lifting or otherwise manipulating the breast. The breast meridian is visualized and marked as it defines the longitudinal axis of the breast. This line extends from the clavicle down to and below the inframammary fold. The top of the pe-riareolar pattern is marked by measuring up from the inframammary fold 4 cm in the midline. A horizontal line is drawn across the chest at this point and, where this line intersects the breast meridian, identifies the top of the pattern (Fig. 6.1). This point can be checked by using the familiar maneuver of placing the fingers of the left hand under the breast and palpating with the fingers of the right hand anteriorly on the breast to estimate the location of the fold. Alternatively, a direct measurement from the midpoint of the clavicle down to this uppermost mark can be made, with this distance measuring 21-24 cm in most patients.
The inferior skin envelope is determined by direct measurement. An 8-cm pedicle width is diagrammed centered on the breast meridian. On either side of the pedicle and extending from the inframammary fold upward, a measurement of 8 to 10 cm is made. These two marks are then smoothly communicated in a line that parallels the inframammary fold (Fig. 6.2). This identifies the skin envelope that will be maintained in-feriorly,with the 8-cm longitudinal measurement being
used in cases of mastopexy and small reductions of less than 400 g and the 10-cm measurement being used in reductions of 800 g or more.
The medial and lateral portions of the periareolar pattern are determined by gently lifting the breast with the left hand up and out, and then up and in, thus allowing the breast meridian to be transposed onto the medial and lateral breast skin level with the nipple (Figs. 6.3,6.4). This maneuver is designed to mimic what the breast will look like once it is reduced, so when lifting the breast slight pressure is applied to create a rounded contour laterally and medially before marking the lateral and medial portions of the periare-olar pattern. Marking these points in this fashion ensures that enough skin will be preserved medially and laterally to comfortably wrap around the inferior pedicle after reduction without creating undue tension. A measurement can be made from the midsternal line to the medial mark at the level of the nipple, and this distance should measure at least 12 cm in most cases.
Once these four landmarks are identified, they are smoothly joined together to create an elongated oval. The inferior pedicle is drawn in with the superior portion of the pedicle skirting the areola by a distance of 2 cm. It is helpful conceptually to crosshatch the skin that will be removed from around the pedicle and identify the skin of the inferior pedicle to be deepithe-lialized with dots (Fig. 6.5). A final measurement is made reflecting the width and length of the periareo-lar pattern. This measurement is helpful as a guide in predicting the difficulty of managing the redundant skin envelope of the breast. Measurements of 15 cm or less pose little difficulty in breast shaping, while measurements of 15 to 20 cm can occasionally cause difficulty. In cases where the dimensions of the periareo-lar pattern measure more than 20 cm,experience with the technique is required to obtain the optimal result.
Generally speaking, most cases of breast reduction in my practice are still performed under general anesthesia and include an overnight stay in the hospital. However, cases of mastopexy and smaller reductions of 500 g or less are often performed in an outpatient setting. In preparing for the SPAIR procedure, several details are best managed ahead of time. Inherent in the SPAIR procedure is assessment of the shape of the breast during the procedure, as one of the operative goals is to create an aesthetically appealing breast immediately. This must be done with the patient upright at least 80°. Therefore, an operative table that will sit up to this degree is mandatory.
Preoperative communication with the anesthesiologist will facilitate fluid management of the patient to allow the sitting position without creating significant hypotension. A long ventilatory circuit will also allow the upright positioning of the patient to be accomplished without excessive manipulation by the anesthesiologist. The arms of the patient are extended outward 90° on padded arm boards and are gently secured with towels and gauze wraps. The head is supported on a foam headrest, and the knees are supported by a pillow to ease strain on the back. During the draping of the chest, care is taken to ensure that the tops of the shoulders can be seen to make certain that malposition of the shoulders does not adversely influence the correct assessment of nipple-areola complex position or the location of the inframammary fold.
The procedure is begun by injecting the margins of the proposed incisions and the areas to be initially deepithelialized with a diluted solution of lidocaine with epinephrine. This dramatically reduces oozing, particularly in the area of the inferior pedicle. A breast tourniquet is applied and the center of the nipple marked. Using a multidiameter areola marker, a circle measuring 52 mm in diameter is marked on the existing areola. Most patients undergoing breast reduction can accommodate this measurement with the areola under stretch without difficulty. When the areola is smaller than 52 mm, the initial incision is made as big as the existing areola allows. The strategy behind this measurement is to make the initial areolar incision larger than the ultimate periareolar defect. Since the diameter of the periareolar defect will be controlled with the Gore-Tex purse-string suture, and this defect will be sized at 40-44 mm, little tension will be applied to the areola, thus allowing the 52-mm areola to rest comfortably within the 44-mm opening. This avoids a stretched-out or pasted-on appearance to the nipple-areola complex.
Initial incisions around the areola, inferior pedicle, and periareolar pattern are now made. The inferior
Fig. 6.7. After the flaps have been developed, the excess breast tissue, along with the inferior pedicle, can be essentially delivered from within the confines of the flaps. The flaps themselves have volume and structure that contribute to the overall shape of the breast pedicle within the periareolar pattern is deepithelial-ized, as is a 5-mm segment of skin around the periphery of the periareolar pattern. Bovie cautery is used from this point on to complete the remainder of the procedure. The dermis is divided around the inferior pedicle and around the periphery of the periareolar pattern at a point 5 mm in and away from the initial epidermal incision. This creates a 5-mm dermal shelf into which the Gore-Tex purse-string suture will eventually be placed. The tourniquet is released and the medial, superior, and lateral flaps are developed.
Initial flap dissection is performed directly under the dermis around the periareolar pattern from the lateral border of the pedicle around to the medial border. It is here that most bleeding will be encountered as there are often large veins coursing radially away from the center of the breast. After the dermal shelf has been developed, dissection gradually angles down to the chest wall medially and superiorly until the pec-toralis major fascia is identified. The thickness of the flaps at the base of the breast medially and superiorly is generally 4 to 6 cm. Laterally, dissection is performed at the level of the breast fascia extending down to the previously marked lateral border of the breast. In this manner, a flap 2 to 3 cm thick is created, with the dissection merging smoothly with the thicker superior flap. Care is taken to be certain that flap dissection extends down to the medial and lateral base of the inferior pedicle, without inadvertent undermining of the pedicle (Fig. 6.6).
The end result of this dissection strategy is the creation of a thin initial flap that will wrap around the inferior pedicle without tension or tissue crowding around the areola. As the flaps become thicker, the su perior and medial borders of the breast become defined and, along with the inferior pedicle, significantly determine the overall shape of the breast. Experience has shown that if the lateral flap is kept too thick, excessive lateral fullness will result, creating an overly wide, "boxy" appearance to the breast. At this point the bulk of the breast has been essentially delivered from within the confines of the flaps (Fig. 6.7). The inferior pedicle is now skeletonized, evenly removing the redundant tissue from around the nipple and areola. Again, care is taken not to undermine the pedicle. This is the same maneuver that is performed in the traditional inferior pedicle Wise pattern breast reduction.
After removal, the specimen has the shape of an elongated horseshoe that is slightly longer laterally than medially. Once the breast has been reduced, the remaining parenchyma is prepared for the placement of shaping sutures. The upper flap is undermined at the level of the pectoralis major fascia for a distance of 6 to 8 cm. Likewise, the medial flap is undermined up to but not past the internal mammary perforators. The ledge created along the upper flap junction with the pectoralis major, where undermining was initiated, is then transposed superiorly and sutured to the pectoralis fascia. This has the effect of using the patient's own breast parenchyma to autoaugment the upper pole of the breast and correct any preoperative upper pole concavity. Often only one suture of 3-0 monofilament is required, although as many as three sutures may be required in cases of extreme ptosis to adequately fill in the upper pole of the breast. It is sometimes helpful to perform this shaping maneuver with the patient upright
Fig. 6.9. With removal of excess tissue from around the inferior pedicle, the resected specimen is seen to have the shape of a horseshoe. In addition, the inferior pole of the breast has been plicated together to create a smooth, even contour so the immediate effect of the flap transposition can be seen.
Next, the same ledge medially is plicated to itself with one suture. This has the effect of gathering the base of the medial flap to help create a rounded appearance in the breast medially. Lastly, the base of the inferior pedicle is sutured centrally to the pectoralis fascia. This helps centralize the pedicle and keeps it from tending to fall off laterally, resulting in loss of projection and excess lateral fullness. Breast reshaping with these sutures is performed only in cases of excess concavity in the upper pole of the breast preop-eratively. Some patients, particularly those who are over their ideal body weight by 20 pounds or more, actually present with no upper pole concavity and therefore do not require the extra flap mobilization as described. In these cases, the inferior pedicle is simply sutured into position centrally and the operation proceeds.
The patient is now brought into a sitting position of 60°, and the upper portion of the pedicle is grasped with a heavy clamp. Traction is exerted upwards on the pedicle until the tissues on either side of the pedicle begin to fold. Two small folds in the skin envelope are created by this maneuver, and the inferior margins of these folds are grasped and stapled together. This point is called the key staple point as it sets the remainder of the inferior skin pattern. A hemostat is applied to the deepithelialized dermal border next to the staple, and again upward traction is now applied to the skin envelope of the lower pole of the breast. The redundant skin is plicated together progressively, again with staples, until a smooth, even, and aesthetic breast contour is created (Figs. 6.8, 6.9). The medial skin margin will be longer than the lateral skin margin, which necessitates making a gradual adjustment as these staples are placed. It is best to take up the major portion of the length discrepancy in the central portion of the vertical plication as it makes the overall shaping of the inferior pole easier.
An attempt is made to not extend the plication line below the inframammary fold. If further skin plication is required, as often happens in reductions larger than 500 g, then the plication is gently curved out laterally until the desired shape is created. Only in cases of mastopexy or reductions of less than 400 g does the vertical incision run straight down to the in-framammary fold as in the classical vertical mam-maplasty. Once an acceptable shape has been created, the skin plication line is marked with a surgical marker and cross hatches are marked to aid in closing the inferior incision. The staples are removed, revealing a wedge-shaped segment of the inferior skin envelope that will need to be removed in order to remove the redundant skin and cone the breast. In the region of the inferior pedicle, the skin is simply deep-ithelialized. Medial and lateral to the inferior pedicle, a full-thickness wedge of skin and parenchyma is removed. Typically this involves only a small segment of tissue medially, but laterally the entire length of the inferior skin flap is eventually incised. This full-thickness release of the lateral flap facilitates subsequent transposition of the lateral flap on top of the deepithelialized inferior pedicle as it is joined to the medial flap during closure of the vertical segment, thus preventing bunching or gathering of tissue during closure, which can distort the shape of the lower pole of the breast. If desired, a drain is placed at this point and brought out through an inferolateral stab incision. Drains are typically used in reductions of 800 g or more. The vertical incision is plicated back together with temporary staples and closed with 4-0 absorbable monofilament sutures placed in an inverted interrupted fashion followed by a 4-0 running sub-cuticular suture.
The periareolar opening is larger than the areolar diameter at this point. It is closed down with a purse-string suture of CV-3 Gore-Tex. This suture is ideally suited for this purpose as it is supple, strong, and has an extremely smooth surface, which allows it to glide easily through tissue without catching. The suture is available on a straight needle specifically designed for use as a purse-string suture. The goal of placing the suture is to use the straight needle to pass the suture directly in the substance of the dermal shelf created during flap elevation. The knot is always placed at the medial border of the periareolar opening, which allows easy identification and removal if desired at a later date. The knot must be buried below the flap; thus the suture placement is begun by passing the needle from deep to superficial and then from superficial to deep to finish. Once the purse string is completed, the suture can easily be slid around the entire periareolar opening to evenly distribute any wrinkles or pleats that may have formed to minimize their effect on the closure and maximize the likelihood that they will settle completely.
The periareolar opening is cinched down to what is usually an oval shape 35 to 40 mm in diameter. The patient is then raised into the upright position of at least 80°, and the periareolar opening will form an elongated oval extending from superomedial to inferolateral, especially in the larger reductions. This opening must be converted into more of a circular configuration. The areolar marker can be used to outline a 44-mm-diameter opening, or, alternatively, the circular diagram can be drawn freehand. The additional skin is deepithelialized,with care being taken not to inadvertently cut the Gore-Tex suture. The areola is inset into the periareolar defect with eight evenly spaced inverted interrupted 4-0 absorbable monofilament sutures followed by a running subcuticular suture around the areolar closure to finish the procedure.
Usually one breast is completed before work on the opposite breast is started; however, performing the operative steps alternatively on each breast may provide better control and enhance the likelihood of obtaining better overall symmetry, especially if any degree of preoperative asymmetry is noted. Once closure is completed, the skin edges are treated with a topical adhesive followed by wound edge support with steristrips. The incisions are dressed with clear plastic sheeting, and a support garment is applied simply for comfort and to control swelling.
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