Breast reduction is a surgical procedure to decrease the size of enlarged breasts. Enlarged breasts cause functional and appearance problems. The excessive weight often results in complaints of upper torso pain, neck pain and possibly upper extremity sensation problems. Affected women often suffer from “bra strapping” (deep grooves on the shoulders caused by bra straps), rashes and skin macerations under the breast and find it difficult to participate in sports or find clothing. In addition, they often feel self conscious due to the size of their breasts.
Breast reduction is a very frequently asked for procedure in our Caribbean plastic surgery clinic at Trinidad Institute of Plastic Surgery. Clients from Trinidad, Guyana, Barbados, Jamaica and the remainder of the Caribbean ask for it on an almost daily basis. Woman from the islands tend to have bigger breasts than Europeans or Americans. As opposed to the public health systems in the latter locations, breast reduction is generally not covered by private or public health insurances in Trinidad or the Caribbean.
Quality of life studies conducted before and after breast reduction surgery found an impaired preoperative quality of life comparable to having to live with a chronic disease such as stable angina or life with a kidney transplant, while these scores approached the population average after breast reduction.
Breast reduction is aimed at reducing the size and thus weight of the to alleviate the aforementioned complaints. As this is a purely mechanical problem addressed by an appropriate mechanical strategy (surgical removal of excess breast tissue) it tends to be very successful with more than eighty percent of patients being very satisfied and regretting not having had the surgery earlier.
In addition to removing excess weight the surgical techniques employed at Trinidad Institute of Plastic Surgery are also designed to reshape the breast and create a more natural, smaller and uplifted appearance. These considerations however are secondary to the functional gains.
The main tradeoff in breast reduction surgery are the permanent scars resulting from the operation. The still most widely used scar pattern is the inverted T or anchor closure results in scars in the fold under the breast and vertically from the fold to and around the nipple-areola complex. Depending on the breast it may be the way to go. However, at Trinidad Institute of Plastic Surgery we try to either use the vertical or horizontal limb of the inverted T plus the scar around the nipple-areola complex thus reducing the length of scars and decreasing the likelihood of scar related problems after the procedure.
Short scar reduction techniques for breast reduction refer to operations trying to avoid the long inframammary scar in the design of the skin reduction pattern.
The idea was first published by the German surgeon Lotsch in 1923 and with a modification in 1925. His two techniques were equally applicable to breast reduction and breast lifting. One of the eternal principles resulting from the revolution in breast surgery in Europe between 1920 and 1930 is the paradigm that reshaping of the breast and reduction of the skin envelope are the two pillars for successful cosmetically acceptable results in breast surgery. Thus the short, vertical scar can be employed in conjunction with almost all reshaping and nipple-areola repositioning techniques. This technique goes nicely with the principal paradigm of all cosmetic surgery at Trinidad Institute of Plastic Surgery – we create structure as structure is beauty, the skin just drapes over it.
Some 60 years later Lassus and Marchac in France and Lejour in Belgium expanded upon Lotsch’s discoveries and made one more of its qualities apparent, which may not have been truly appreciated by Lotsch’s contemporaries (see also “Deformities and Cosmetic Operations of the Female Breast”, by Hermann Biesenberger). When breast reshaping was carried out by resecting the lower and lateral drooping and enlarged breast tissue and carrying the nipple-areola complex on one of the superior pedicles durable uplifting, a smaller footprint of the breast base on the chest wall and a dramatic increase in projection could be achieved. Not only was the scar vertical, but the entire concept is one of movement in a vertical direction – namely up. Thus, “vertical breast reduction” is a term still in common use in Europe.
The second alternative is accepting the scar in the fold under the breast and around the nipple-areola complex but avoiding the scar from the fold to the nipple-areola complex. In 1925 Raymond Passot contended that this is the most advantageous scar pattern. Decades later this idea came to be termed “no vertical scar” breast reduction, as it avoids the scar connecting the periareolar with the inframammary scar as used in the popular inverted T pattern or combination of periareolar scar and vertical scar only as employed in vertical, short scar techniques.
I find Passot’s technique favorable in darker skinned patients, who tend to form unfavorable scars and are prone to hypertrophy and long lasting dyspigmentation. While this occurs infrequently in the periareolar scar, it is not unheard of and may become disturbing in a visible, vertical scar on the breast. An unfavorable inframammary scar on the other hand remains hidden. Passot’s technique is applicable in cases of extreme gigantomastia or long breasts. Shaping the breast in Passot’s operation may require internal modifications in an effort to avoid the bane of the technique, which is a slightly more boxy than rounded shape.
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