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THE "LONG" AND THE "SHORT" OF IT...
Few will disagree that women who undergo breast
reduction surgery are amongst the most satisfied patients
in any plastic surgery practice. Numerous studies have validated
the improved quality of life that follows this surgery. Backache,
neck and shoulder ache, poor posture, bra strap pain, and limited
ability to participate in sports are just some of the reasons
why women with large breasts seek help.
Currently, there are essentially 3 different surgeries (and variations
there-of) available to patients seeking breast reduction. I will
concentrate of the 2 "open" surgeries most commonly
performed, but it may be useful to know that liposuction
is occasionally an option for patients requesting moderate breast
improvement / volume reduction. Ideal patients for this surgery,
are those with little or no ptosis (droop) and breasts that are
predominantly composed of fatty tissue(as opposed to breast tissue
itself, which is quite fibrous). The effect of liposuction is
to decrease breast volume, but little or no lift is achieved.
It does however, offer some patients volume reduction with little
or no obvious scarring.
Anatomy:
A breast is composed of a skin envelope, containing a "parenchyma"
composed of varying proportions of fatty tissue and breast / fibrous
tissue. As you will read below, some breast reduction techniques
focus mainly on altering the skin envelope, and use this to shape
the underlying content. More recent techniques have shifted this
focus to concentrate on shaping the breast content (parenchyma)
and allowing the skin envelope to re-drape. This "philosophy"
of moving away from skin tightening and towards effecting change
through manipulation of deeper tissues is also found in modern
facelift techniques.
Tradional / Long Scar / Wise Keyhole Breast Reduction
Developed in 1956 by Dr Wise, this is probably still the commonest
method used for breast reduction today. Like all surgeries, it
has some advantages, as well as some disadvantages.
Advantages: It is easy to perform, easy to teach and
easy to learn. It involves the application of a "fixed"
skin pattern design which results in an "anchor" type
of scar on the breast (around the areola, a vertical scar to the
breast fold, and a long scar underneath the breast, in the fold,
from side to side). It can be used for small reductions, lifts,
as well as very large reductions, and the results are generally
good.
Disadvantages: The major disadvantage is the extent of
the scarring, the quality of which can be good or bad, depending
on the patient's skin type, and wound healing ability. In addition,
the breasts are occasionally slightly under projected, and tend
to "bottom out" with time - this may well be due to
the fact that the breast content is not specifically addressed
in this surgery, but rather, the shape of the content is determined
by the skin pattern design which removes excess skin in both the
vertical and horizontal planes.
Short Scar / Vertical Mammaplasty
In an attempt to decrease the scar burden of the Wise pattern
reduction, some innovative plastic surgeons (notably from France)
looked at ways to perform a breast reduction without the need
for a long horizontal scar in the breast crease. This vertical
breast reduction has undergone several refinements over the years,
and is only more recently gaining wider acceptance. I was fortunate
enough to attend a course in San Diego in 2003 given by Dr Elisabeth
Hall-Findlay who has refined the technique, and whose method I
tend to follow when doing this surgery.
Advantages: Interestingly, the main reason for pursuing
this operation (i.e. the shorter scar) is not
the major benefit of the surgery. Although the scar is shorter
(and the operating time somewhat less) the main advantage
appears to be the improved breast projection
gained from shaping the parenchyma
(content) by using sutures in the breast substance to maintain
this projection over time. Conceptually, this is a "breast
content shaping" operation, rather than a "skin shaping"
operation. In addition, the breast base is narrowed somewhat,
and the breast fold is lifted.
Disadvantages: The operation is more difficult to teach,
to learn and to perform, as no "fixed pattern" is used
- hence some degree of experience is needed. That said, this operation
does have a slightly higher minor revision rate (small scar revisions
etc) than the Wise pattern , even in the best hands. Another disadvantage
is that this technique is not suitable, in my opinion, (and hands!)
for larger reductions (over about 500g per side), where I still
tend to favour the Wise pattern. Lastly, patients need to be made
aware that the breasts will often take a minimum of 3 months to
look more natural - they usually have a slightly odd shape early
post- op, and the skin of the lower pole is often pleated (much
like a curtain pushed together on a rail) initially.
Despite these "trade-offs", the improved
projection, lesser scarring,
and probable better long term stability
of results, make this an attractive option in well selected patients.
Breast Lift / Mastoplexy
A few words about mastopexy / breast lift.
A mastopexy is done when there has been failure of the breast
envelope (skin) to maintain the parenchyma (content) in an aesthetic
form, and hence the breast droops, and appears elongated. This
often follows massive weight loss, pregnancy and breast feeding.
A "reduction" of sorts is often needed, with the emphasis
on reducing the envelope, rather than the content, and indeed,
in some cases, "content" is added by way of an implant
to restore breast volume.
It therefore follows from the above, that any technique which
aims to tighten a stretched skin envelope as it's principle
goal (so-called "dermal mastopexy" or
"skin lift") is fundamentally flawed, since the skin
did not do a very good job of maintaining the content in the first
place, and hence, this procedure is likely to fail (bottom out)
in a relatively short space of time. It is important, I believe,
to do a comprehensive "parenchymal rearrangement"
in these patients, much as one would do with the short scar breast
reduction technique described above, in an attempt to get some
stability of the result, and focus one's attention on reshaping
the breast content (and if need be, adding an implant) rather
than trying to tighten an already stretched / failed skin envelope.
If you have any questions about this, feel free to email
me
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