V

j ^V9o/o 1 II Breast Surgery 16%

'| ■'/ Reduction 17%'; Augmentation 13% ^^r \ (Systemic al iegaUons excluded} ^^ \ Re construction 6%

k. Rhinoplasty 22%

Fig. 13.1. Malpractice claims filed from Corney [28]

breast contouring. This technique was applied by many surgeons for small reductions but was not as well received for large reductions due to the increased incidence of vertical scar healing problems [17,18]. In the last few years many modifications have been proposed in an attempt to reduce complications and to make this technique more applicable to larger breast reductions [17-21]. Basically these modifications included elimination of gland suturing to the chest wall, fewer internal gland sutures, minimizing skin undermining, and avoiding liposuction or limiting it to the lateral breast and axillary areas.

No operations are without problems or complications, and breast reduction is no exception. Looking at aesthetic surgery as a whole, breast reduction surgery in the U.S. is second only to rhinoplasty in the number of malpractice claims filed over the last 10 years (Fig. 13.1). Most problems are common to all breast reduction techniques and involve nipple-areola viability, nipple-areola sensation, delayed healing, scars, breast shape and projection, nipple malposition, hematoma, seroma, and infection (Table 13.1). The most serious complication is nipple-areola/breast necrosis, while the most common problem is imperfection of breast shape. The incidence of complications and revision rates associated with limited incision breast surgery are related to the learning curve, body mass index (BMI), breast size, and skin manage

Table 13.1 Problems common to all breast reduction techniques Table 13.2. Factors related to the incidence of complications and revision rates in limited incision breast surgery

Immediate problems

Delayed problems

Nipple-areola viability

Delayed healing

Hematoma

Scars

Seroma

Breast shape and projection

Infection

Nipple malposition

Learning curve Body mass index (BMI) Breast size Skin management

Learning curve Body mass index (BMI) Breast size Skin management

ment (Table 13.2). It is our experience and opinion, as well as of others [15,22], that the rate and severity of complications are related more to patient BMI and breast size than to the type of operation performed. In this chapter we will discuss the problems associated with vertical scar mammaplasty and possible preven-tative solutions.

No pedicle is without risk regardless of technique used. We have all seen nipple-areola problems with all types of pedicles. While the superior pedicle used with vertical reduction is reliable, the dermal extension may not always be as dependable. Breast size or volume of resection is not as important to nipple viability as the distance upwards that the nipple has to move.

To reduce complications with nipple-areola viability, a number of possible preemptive measures should be considered. The surgeon should always be diligent to recognize and preserve perforators to the superior pedicle in order to avoid injury to the arterial supply of the nipple-areola complex (Fig. 13.2). Therefore, a thorough understanding of the arterial anatomy of the breast is essential for avoiding tissue loss. Another caveat is that the longer the pedicle, the thinner it should be in order to facilitate insetting of the areola (Fig. 13.3). It is important to bear in mind also that the longer the pedicle,the wider it must be in order to preserve vascularity (Fig. 13.4). If difficulty is encountered with insetting the areola, cautious liposuction can be used to make this possible. In high-risk patients, a double pedicle (i. e.,vertical bipedicle) should be considered.

Blue discoloration of the areola after insetting is a sign of venous impairment and is usually due to either tension on the areola or kinking of the pedicle. This change in color is a sign of impending necrosis and should be addressed immediately. If signs of venous compression are present, the sutures should be removed and the cause of the tension or twisting corrected (Fig. 13.5).

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