Aesthetic Surgery Journal Advance Access published February 23, 2016
Breast Surgery
Vertical Sculpted Pillar Reduction Mammaplasty in 317 Patients: Technique, Complications, and BREAST-Q Outcomes
Aesthetic Surgery Journal 2016, 1–14 © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjv217 www.aestheticsurgeryjournal.com
Brian M. Derby, MD; James C. Grotting, MD, FACS; and David T. Redden, PhD
Level of Evidence: 4
Accepted for publication September 17, 2015. Reduction mammaplasty is a commonly performed surgical procedure. The American Society of Plastic Surgeons reported that 41,309 aesthetic breast reductions, and 59,883 reconstructive breast reductions, were performed in 2014.1 The objectives of reduction mammaplasty include gland resection, relocation of a ptotic nipple to a more anatomically aesthetic location, resection of skin excess, and provision of a durable, aesthetic breast shape. A variety of techniques exist for preservation of nipple blood supply, gland shaping, and skin redraping that facilitate preservation of aesthetic breast appearance after reduction surgery. Algorithms have been provided to delineate those seeking the procedure primarily out of medical necessity for relief of upper back/neck/shoulder/arm pain, rashes, grooving, and
Therapeutic
Dr Derby is a plastic surgeon in private practice in Sarasota, FL. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; a Clinical Professor, Division of Plastic and Reconstructive Surgery, University of Wisconsin, Madison, WI; and is the CME/MOC Section Editor for Aesthetic Surgery Journal. Dr Redden is the Chair, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL. Corresponding Author: Dr James C. Grotting, Grotting and Cohn Plastic Surgery, 1 Inverness Center Parkway, Suite 100, Birmingham, AL 35242, USA. E-mail: [email protected] Presented at: the 58th Annual Scientific Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons in Amelia Island, FL in June 2015.
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Abstract Background: The senior author (JCG) has described the vertical sculpted pillar breast reduction. Objectives: This manuscript aimed to compare this technique’s safety profile to other established techniques via complication rate reporting. Few studies have utilized the BREAST-Q for long-term outcomes reporting in bilateral reduction mammaplasty patients. BREAST-Q outcome comparisons, between cosmetic and insurance-based breast reduction cohorts, have not been previously reported. Methods: A retrospective chart review was performed on patients who underwent reduction mammaplasty using the vertical sculpted pillar technique. The BREAST-Q postoperative reduction mammaplasty module was administered. Complication rates and outcomes data were compared among patient cohorts distinguished by pedicle, scar pattern, and payor population. Statistically significant differences were set at P < .05. Results: Compared to the superior pedicle, use of the superomedial pedicle statistically increased rates of postoperative fat necrosis in this series. Complication rates did not differ among scar patterns, but use of a J, L-shaped, or short-T scar decreased the need for secondary/revisional surgery. Cosmetic and insurance-based outcomes did not differ in any domain of the postoperative reduction mammaplasty BREAST-Q module. Conclusions: Complications data for the vertical sculpted pillar reduction mammaplasty were comparable to published results for other techniques. Complication rates are unaffected by scar pattern. Superomedial pedicle selection and larger insurance-based reductions may predispose to statistically significant increases in fat necrosis compared to use of the superior pedicle. Payor source neither affects the majority of complication rates, nor BREAST-Q satisfaction and quality of life domains. This information can be used to improve management of expectations during the preoperative consultation process.
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METHODS A retrospective chart review was performed on a series of insurance and cosmetic primary bilateral breast reduction mammaplasty patients who underwent the vertical sculpted pillar reduction mammaplasty by the senior author from February 2003 to May 2015. Inclusion criteria included female patients undergoing primary bilateral reduction mammaplasty. Exclusion criteria included: male gender, unilateral reduction mammaplasty, prior history of breast reconstruction, and/or a personal history of breast surgery (ie, lumpectomy, reduction
mammaplasty, augmentation mammaplasty, mastopexy). The inclusion/exclusion criteria were established to ensure that the postoperative reduction mammaplasty BREAST-Q reporting module was administered to a homogeneous cohort of primary reduction mammaplasty patients. Three hundred and eighty-six (386) patients were identified as possible candidates for inclusion after an electronic medical record search using the keywords “reduction mammaplasty” and “breast reduction.” Of these, 317 patients met inclusion criteria. Variables such as patient age, height, weight, body mass index (BMI), smoking history, weight of reduction specimens, superior or superomedial pedicle usage, scar pattern, and complications were extracted, and entered into a Microsoft Excel (Microsoft, Inc. Redmond, WA) data acquisition spreadsheet. Complications included seroma/hematoma, fat necrosis, nipple-areolar complex (NAC) necrosis, skin loss, scar revision, and breast dehiscence. Total and specific complication rates were tabulated and compared statistically with respect to scar pattern, pedicle, and payor source (cosmetic vs insurance-based). Patients were also provided with the postoperative BREAST-Q reduction mammaplasty module, a validated patient-reported survey for breast outcomes studies.12 The BREAST-Q was administered at an average 73 months (6.1 years) postoperatively. Personal correspondence with Amy Alderman, MD, has confirmed the validity of BREAST-Q outcomes study at 6 years postoperatively. Dr Alderman has been instrumental in the development of outcomesbased study within our field. Outcomes data were tabulated, summarized, and statistically analyzed. Statistical analyses began by calculating measures of central tendency (sample mean, sample medians) and dispersion (variance, standard deviation) for continuous outcomes by group (cosmetic, insurance, superomedial, superior). Categorical variables were summarized as sample proportions by group. To test for mean differences between groups on continuous outcomes, two-sample t test were conducted. To test for differences in proportions, chi-square analyses were conducted. Careful attention was given to all statistical assumptions for these procedures and to gauge sensitivity to these assumptions, non-parametric procedures (Wilcoxon Rank Sum) for continuous outcomes and Fisher’s exact test for proportions were also conducted. Given all approaches generated identical inferences, we have chosen to report the two-sample t tests and chi-square analyses. All analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC) with a Type I error rate of 0.05. Patients were provided with, and signed, informed consent for use of their personal health information utilized in this review. Institutional Review Board approval was obtained from the University of Alabama at Birmingham (Protocol #X141016001).
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numbness vs those desiring aesthetic improvement alone.2 While symptom alleviation is important, one’s choice of technique should provide the patient with a long-lasting, aesthetic result. From Dieffenbach’s first account of reduction mammaplasty in a woman,3 it has been evident that every technique has its limitations and advantages.4-10 Pillar sculpting became popularized by Armando Chiari Jr., who also emphasized the concept incorporated into every reduction mammaplasty performed in this practice – what is most important in a reduction mammaplasty is the tissue left behind, not that resected.8,11 It was the senior author’s (JCG) personal experience with Dr Chiari that prompted the integration of pillar sculpting into the presented reduction technique to maximize conical shaping of the breast. The aim of this manuscript is to demonstrate how the positive attributes of the more commonly practiced reduction techniques have been distilled down, and combined into a procedure that the senior author has entitled vertical sculpted pillar reduction mammaplasty. The technique narrows the breast base, empties the lower pole of the breast along a central and inferomedial/lateral Wise pattern parenchymal resection, bases the nipple on a superior or superomedial well-vascularized pedicle, and offers a shorter scar. Pillars are sculpted such that they narrow the breast and obliterate dead space when brought together like the pages of an open book, and deproject the breast when their resected concave bases rest upon the convexity of the chest wall. These efforts are intended to provide a very pleasing, durable, conical breast shape through “sculpting” maneuvers. This manuscript also aims to provide the reader with a descriptive technique reference to facilitate incorporation of the vertical sculpted pillar breast reduction into their practice should they recognize the benefits this technique has provided the senior author over the last twelve years with hundreds of patients. It is an easy technique to teach and comprehend. Finally, this manuscript aims to add to the growing body of standardized patient-reported outcomes data through the postoperative administration of the BREAST-Q to a series of patients.
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Operative Technique Preoperative Markings
from the 6 o’clock position of the areolar marking. A Wise-pattern parenchymal resection is then marked obliquely from the inferior aspect of each vertical pillar marking, and drawn to meet the inframammary fold. The vertical limb markings are joined inferiorly in an elliptical fashion, approximately 2 to 3 cm above the inframammary fold. Areas of anticipated axillary liposuction are marked for lateral breast border definition. The most caudal portion of the superior pedicle is then marked inferior to the NAC, sparing only 1 to 2 cm inferior to the NAC as this tissue does not contribute to blood supply (Figure 3). A video demonstrating the preoperative markings is available as Supplementary Material at www. aestheticsurgeryjournal.com.
Intraoperative Details Local anesthetic (0.5% lidocaine with epinephrine [1:200,000]) is infiltrated in a standardized, sequential manner to facilitate relatively bloodless pedicle de-epithelialization, parenchymal resection, and pillar development. We have found the most effective area to infiltrate, to minimize intraoperative bleeding, is the plane between the gland and pectoralis muscle.
Subglandular Undermining. Attention is then turned towards deepening the incision, inferior to the base of the pillars, within the level of the mastectomy plane down to the chest wall. The central parenchymal tissue is then elevated off of the chest wall in the subglandular plane. The surgeon should exercise caution at this point, as it is easy to enter the subpectoral plane. Dissection is carried to the level of the anterior branch of the fifth intercostal perforator, which has been found to be universally present. Once this vessel is
Figure 1. Creating the lateral breast contour, as demonstrated on a 21-year-old woman. Firm medial traction atop the breast is aimed at creating the most pleasing lateral breast contour possible prior to incising along the pillar.
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The patient is marked in the standing position with the surgeon seated in front of her. The sternal notch and abdominal midline are marked. Evidence of scoliosis, shoulder height asymmetries, discrepancies in breast width/volume, and dissimilarities in nipple position may be identified at this time. The inframammary fold is marked. The chest wall meridian, breast meridian, and superior margin of the breast mound are then marked. From anecdotal discussions with Dr Elizabeth Hall-Findlay, the superior breast border can be identified by observation of the upper chest wall crease formed with gentle superior pressure applied to the inferior pole of the breast. To identify the new position of the NAC, the surgeon’s fingertips are placed at the inframammary fold, and the breast is allowed to drape atop the fingertips. The location of the fingertips is transposed to the anterior surface of the breast, and a small transverse marking is made perpendicular to the breast meridian at the corresponding location (the A point of Pitanguy). This mark identifies the future location of the superior margin of the areola, not the nipple, and ideally lies 10 cm inferior to the previously marked superior border of the breast mound. Care must be taken to confirm that this new nipple position lies at the most projecting part of the simulated reduction/lift by pinching the breast skin with both hands using the Lassus maneuver (see description below). The medial and lateral vertical limbs/pillars of the vertical reduction pattern are then marked with a gentle, but firm, lateral and medial displacement of the breast. Markings are made in line with the chest wall meridian. Focusing on the amount of skin and breast tissue to be left behind with this maneuver ensures aesthetic breast shaping upon pillar and skin closure. This concept becomes particularly apparent with medial displacement of the breast, when attention is directed towards marking the future location of the lateral vertical limb/pillar that creates the most pleasing lateral breast contour (Figure 1). Attention is then directed towards ensuring that the new NAC position correlates with the most projecting part of the simulated reduced breast mound. Using the Lassus maneuver the surgeon’s fingertips straddle the two vertical limb markings, followed by a centrally directed pinch at the anticipated 6 o’clock position of the NAC for the reduced breast (Figure 2). This move simulates closure of the new areolar circumference. The desired locations of the 6 o’clock areolar position are marked transversely, crossing perpendicularly through the superior aspect of the vertical limb markings. The areolar circumference is then marked freehand, often measuring 14 to 15 cm in length. The heights of the medial and lateral pillars are then marked along the vertical limbs, typically measuring 6 cm
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Figure 3. Completed markings demonstrated on a 21-year-old woman. Markings are photographed and kept as part of the patient record.
divided, the remainder of the superocentral dissection is performed bluntly to a level corresponding with the marked superior extent of the breast mound.
mammaplasty technique is available as Supplementary Material at www.aestheticsurgeryjournal.com.
Pillar Height Sculpting. A sponge is then inserted into the centrally dissected tunnel. At this point, one’s attention is turned towards resection of the central gland between the medial and lateral pillars. It is important to conceptualize the pillars coming together like the pages of an open book after central gland resection. Rather than incising perpendicularly from skin to chest wall along the vertical limbs, we prefer to angle the blade medially for the lateral dissection, and laterally for the medial dissection. This blade angle helps sculpt the inner aspect of each pillar like the pages of a large open book, and eliminates dead space upon pillar approximation. The lower border of the pedicle is then incised to a thickness of 2 cm. The resection is carried superiorly to a level halfway between the nipple and the upper border of the breast, and then transitioned into a Pitanguy/keel-shaped excision deep to the superior pole. The margins of the keel excision are made in line with the inner aspect of each pillar incision. Aggressive superior pole tissue resection is avoided in order to maintain fullness (Figure 4). A video demonstrating the vertical sculpted pillar reduction
Pillar Base Sculpting. The pedicle is retracted anteriorly off of the chest wall. A measurement of 6 cm is typically made from the 6 o’clock position of the areola. In taller individuals, with longer chest walls, this measurement can be made at 7 cm to more appropriately fit breast projections in taller frames. It is important to conceptualize creating a pillar shape and height that is proportional to the chest wall. The pillar base must be resected so that the breast is deprojected. A ruler is held flush against the inner aspect of the lateral pillar. The new base of the pillar is marked with methylene blue, taking origin from the previously marked Wise-pattern skin marking on the breast surface, and then continuing across the base so that the height of the pillar is 6 to 7 cm (6 cm in smaller reductions/pexies, 7 cm in larger reductions) (Figure 5). Prior to incising this marking, one should consider the objective of sculpting the pillar base in a concave manner such that it rests anatomically upon the convex chest wall. A 10-blade scalpel is passed from medial to lateral, deeply through the pillar base methylene blue marking, and is then redirected to pass from lateral to medial as the excess parenchymal tissue is resected from
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Figure 2. The Lassus maneuver demonstrated on a 21-year-old woman. Using the Lassus maneuver the surgeon’s fingertips straddle the two vertical limb markings, followed by a centrally directed pinch at the anticipated 6 o’clock position of the NAC for the reduced breast.
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Dressing and Postoperative Care. The dressing mainFigure 4. Medial and lateral pillars after gland excision demonstrated on a 21-year-old woman. The central parenchymal resection between the pillars is appreciated. Wise pattern parenchymal excision has also been performed.
the overlying skin flap. The laterally to medially directed blade minimizes potential injury to the sensory nerve supply entering the lateral pillar. A similar technique is employed for medial pillar base sculpting, but conservative resection is encouraged in order to preserve medial breast bulk. Hemostasis is then obtained (Figure 6).
Marchac Suture, Pillar Approximation, and Lateral Breast Border Liposuction. Anterior retraction on the Adair clamps lines up the pillars for approximation. The Marchac suture is placed prior to pillar approximation, and greatly facilitates superior pole shaping. This suture technique incorporates a 2-0 polyglactin suture passed from the undersurface of the superior gland to the chest wall, as high as possible, to accentuate the roundness of the upper pole. Pillar approximation is then performed. A key 2-0 polyglactin suture is placed through the deep dermis and
tains shapely superomedial breast position afforded by the vertical sculpted pillar technique. Two large, transparent adhesive dressings are applied. They are draped across the breast from lateral to medial, first across the lower pole, and subsequently across the upper pole. The concept is to hold the breast position into the desired shape and position. Care must be taken not to attempt to apply tension to the dressing during placement, as this may result in postoperative skin blistering. A small window is made for the nipple, and a surgical bra is applied. The patient returns to clinic at one week, at which point a larger periareolar window is cut, and areola cleansed. The transparent dressing and nylon sutures are removed at two weeks. The patient may shower on postoperative day one. Antibiotics are continued postoperatively for one week.
RESULTS Patient Demographics The average patient age at the time of surgery was 39.6 years (range, 14-76 years). Average BMI was 28.5 kg/m2 (range, 18.5-46 kg/m2). Patients were followed clinically for an
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superficial fascia at the 6 o’clock areolar position. Pillars are then approximated from superior to inferior, effectively narrowing the breast (Figure 7). Areolar and vertical limb skin is then tailor-tacked. Redundant skin may remain inferiorly, and can be excised in a small J or inverted-T shaped pattern if necessary. Attention is directed towards the lateral breast border. The gentle lateral curve, created by pillar sculpting and approximation, can be appreciated. The curve should be followed to the level of the newly elevated inframammary fold, but is often noted to remain blunted inferolaterally. To enhance the inferolateral pole curvature, another key suture of 2-0 polyglactin suture is placed. This passes from the underside of the gland/lateral pillar base at the level of the new inframammary fold, and then through the pectoralis fascia, typically at the chest meridian. Immediate contouring of the inferolateral breast curvature can be appreciated (Figure 8). Tumescent infiltration (120 mL of 1 L lactated ringer’s/1 ampule of epinephrine/30 mL of 1% lidocaine) followed by suction-assisted lipoplasty offers final aesthetic contouring of the lateral chest wall. We have found that performing the liposuction prior to placement of the lateral pillarshaping suture can be advantageous as it minimizes risk of disrupting this suture with repeated passages of the liposuction cannula. A drain is only used when extensive liposuction is performed. Skin is then closed in standard fashion.
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Figure 6. Lateral sculpted pillar resting upon the chest wall demonstrated on a 21-year-old woman. The 6 cm pillar will rest upon the chest wall, effectively deprojecting the breast after pillar base resection.
average of 11.9 months (range, 0.5-93 months). Reduction specimen weight averaged 566 grams on the left (range, 25-2038 grams), and 540 grams on the right (range, 25-1853 grams), for a total average resection weight of 1106 grams (range, 50-2959 grams). Postoperative BREAST-Q reduction mammaplasty modules were returned for 59 of 317 patients, for a return rate of 18.6%. The questionnaire was administered at an average of 73 months (6.1 years) postoperatively.
Intraoperative Details Scar patterns were reportable for all 317 patients: short-T (51%), J or L-scar (17%), or vertical (32%). A superior pedicle was used in 83% of patients, and a superomedial pedicle was used in 17% of patients (Table 1).
Complication Rates Based on Pedicle Pattern
Figure 7. Pillar approximation demonstrated on a 21-year-old woman. Pillar bases are approximated to narrow the breast.
Superior (n = 262 patients) and superomedial (n = 55 patients) pedicles were compared with respect to postoperative rates of dehiscence, dog-ear or scar revision, fat necrosis, skin loss, hematoma, NAC loss, and secondary surgery. Statistically significant differences were noted between superior and superomedial pedicles for rates of fat necrosis (2.29% vs 9.09%, respectively, P = .02) (Figure 9).
Dog-ear/scar revision rates were 19.08% and 14.55% for superior and superomedial pedicles, respectively, but these differences were not statistically significant. NAC loss and dehiscence rates trended towards more commonly occurring in patients with superomedial pedicle reductions,
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Figure 5. Measuring the pillar height at 6 cm demonstrated on a 21-year-old woman. The ruler is held flush against the face of the lateral pillar from the planned 6 o’clock areolar margin. Pillar height is marked at 6 cm.
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but one must consider that the two nipple losses in the superomedial group occurred in the same patient who underwent reduction mammaplasty with a history of sicklecell trait. She suffered nipple loss at two weeks, comparable to the presentation of nipple necrosis previously reported in the literature in this same patient population.13 While inclusion of the sickle-cell trait patient may inherently skew data, exclusion of any patient who met inclusion criteria for this review may be considered selection bias. It is our hope that by raising awareness of this complication in the patient with sickle-cell trait, we may potentially help other surgeons avoid a similar outcome with a similar patient in their own practice. The superomedial pedicle remains a safe and reliable vascular supply to the nipple in reduction mammaplasty.
Complication Rates Based on Scar Pattern Short-T, J, or L-shaped, and vertical scar patterns were compared with respect to postoperative complication rates for dehiscence, dog-ear or scar revision, fat necrosis, skin loss, hematoma, NAC loss, and secondary surgery. No statistically significant differences in complication rates were noted among the three scar patterns employed intraoperatively (Figure 10).
Complication Rates Based on Payor Source Cosmetic and insurance-based reductions were compared with respect to postoperative complication rates for dehiscence, dog-ear or scar revision, fat necrosis, skin loss,
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Figure 8. Lateral shaping suture demonstrated on a 21-year-old woman. The lateral shaping suture is placed from the base of the lateral pillar to the chest wall fascia at the level of the newly elevated inframammary fold. The suture enhances the inferolateral curvature of the breast. (A, B) Inferior views before and after suture placement. (C, D) Anterior views before and after suture placement.
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hematoma, NAC loss, and secondary surgery. A statistically significant increase in fat necrosis was found for insurancebased breast reduction patients. Payor source did not contribute to differences in rates of occurrence of other reported complications (Figure 11).
Table 1. Patient Demographics
Age (years) 2
Mean ± SD
Range
39.6 ± 14.6
14-76
BMI (kg/m )
28.5 ± 5.5
18.5-46
Clinical follow-up (months)
11.9 ± 12.5
0.5-93
BREAST-Q Scores Based on Payor Source BREAST-Q scores were tabulated for all satisfaction and quality of life (or well-being) scales assessed by the postoperative reduction mammaplasty questionnaire module. Satisfaction scales assessed patients’ postoperative satisfaction with their breasts, overall outcome, nipples, information (about risks, healing, recovery time, details of procedure), plastic surgeon, medical staff, and office staff. Quality of life (or well-being) scales assessed patients’ postoperative psychosocial, sexual, and physical well-being. No statistically significant differences in patient-reported outcomes scales were noted between cosmetic and insurance-based reduction mammaplasty patients (Figure 12).
DISCUSSION
Resection weight (grams) 539.9 ± 293.4
25-1853
Left
566.2 ± 297.2
25-2038
% (n) Pedicle Type Superior
83% (262)
Superomedial
17% (55)
Scar Pattern Short-T
51% (162)
Vertical
32% (100)
J or L
17% (55)
Payor Insurance
69% (220)
Cosmetic
31% (97)
BMI, body mass index; n, number of patients; SD, standard deviation.
Figure 9. Complication rates based on pedicle pattern. A statistically significant difference in complication rates, between the superior and superomedial pedicle, was only seen for fat necrosis.
This manuscript does not advocate for a “better” technique of reduction mammaplasty, as the literature is replete with over 70 technical variations for reduction mammaplasty that work best in various authors’ hands. The “best” technique is the technique that produces few complications and consistently satisfied patients in one’s hands. The aim, instead, was to offer a transparent review of complications and patient-reported outcomes with a technique considered to be an amalgam of principles derived from personal influences, and decades of experience reducing and “sculpting” breast tissue to produce a long-lasting, aesthetic breast shape (Figures 13 and 14, Supplemental Figures S1 and S2).
Sculpted Vertical Pillar Breast Reduction Complications With no prospective randomized controlled trials available on the topic of reduction technique selection, and associated complication rates, surgeons are left to consolidate complications data from level III, or lower, large-scale case series
Figure 10. Complication rates based on scar pattern. No statistically significant differences in complication rates were noted among the scar patterns utilized in this series.
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Right
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Figure 12. BREAST-Q scores based on payor source. No statistically significant differences in patients’ postoperative wellbeing or satisfaction were seen between cosmetic and insurance-based reduction mammaplasties.
when assessing safety of his/her chosen technique.5-7,14-18 The largest review to date, from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database of 3538 breast reduction patients, identified that the risk-adjusted 30-day incidence of any postoperative complication was 5.1%, and that the incidence of major complications (ie, deep infection or return trip to the operating room) was 2.1%.14 Table 2 reports the complication rates for several, recent large scale series of breast reduction and serves as a consolidated reference for the reader. Daane and Rockwell report that complication rates range from 6.5% to 22% in their meta-analysis of five classical reduction mammaplasty techniques. 19 This manuscript sought to uncover potential relationships between complications and pedicle selection, scar pattern, and payor source following sculpted pillar vertical reduction mammaplasty. Lista and Ahmad offer that overall complication rates are higher in medial pedicle vertical reductions compared to superior pedicle vertical reductions (7% vs 5.3% of breasts).7 Antony et al performed a similar, but retrospective, comparison of a prospectively maintained database of vertical and inverted-T reduction mammaplasties.17 The metrics of complication rate reporting vary widely in the literature. Reports cite both “rates per patient” and “rates per breast,” making retrospective or prospective comparison of reported complication rate averages difficult to interpret (Table 2). Superomedial pedicle selection had a statistically significant impact on the incidence of fat necrosis in this series of 317 patients (Figure 9). Trends towards increased incidences of NAC loss and superficial wound dehiscence were also noted with use of the superomedial pedicle (3.64% and 5.45%, respectively, n = 55 patients). The superomedial pedicle was the pedicle of choice in patients with larger reductions – patients who also have higher incidences of fat necrosis. Fat necrosis reportedly occurs
with an incidence of 0.8% to 16% following reduction mammaplasty, depending on reduction size.19 “Per patient” complication rate reporting demonstrates a trend towards higher rates than “per breast” reports.7,15,18,20,21 Despite a 2.29% to 9.09% incidence (per patient) of fat necrosis in this series, no patient required a return trip to the operating room for excision of necrotic fat. Expectant management and massage, over the course of the first postoperative year, led to resolution of focal areas of postoperative parenchymal density. We consider the definition of fat necrosis to be one of palpable breast tissue firmness in the first year following breast reduction surgery. The most definitive way to determine its presence is excision with pathologic diagnosis. We do not typically suggest imaging or biopsy to our breast reduction patients in the absence of pain or skin distortion prior to 9 months postoperatively. Furthermore, in the cosmetic patient population, insurance coverage of the imaging study would likely be an issue. We possibly attribute the increased NAC loss and wound dehiscence rates, seen with superomedial pedicle reductions in this series, to implementation of this pedicle in larger, more ptotic reductions. The same etiology of increased fat necrosis (ie, decreased blood flow due to more extensive parenchymal resection) may have contributed to higher rates of NAC necrosis and wound dehiscence. We make no implication that the superomedial pedicle is a “less safe” pedicle. The literature is replete with its use and the safe, reliable, aesthetically pleasing results it provides for patients who undergo reduction mammaplasty. The superomedial pedicle does not lend itself as well to our technique of pillar sculpting. One cannot resect/sculpt the base of a superomedial pedicle without comprising blood supply. Through experience, we feel the superomedial pedicle should never be thinned nor undermined. Similar to Lista and Ahmad’s recommendation, the selection of a superior or (supero)medial pedicle is dictated
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Figure 11. Complication rates based on payor source. A statistically significant difference in complication rates, between cosmetic and insurance-based reduction mammaplasties, was only seen for fat necrosis.
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by nipple position relative to the mosque dome.7 When the NAC is below the mosque, a superomedial pedicle is selected to permit a more tension free rotation of the pedicle into position upon pillar closure. While this recommendation intends to minimize risk of pedicle compression in the presence of excessive pedicle length,16 density of breast parenchyma may also be a contributing factor to pedicle compression during NAC inset. Dense parenchyma may compromise NAC blood flow during inset of a superior pedicle. Therefore, preoperatively, extent of desired NAC elevation and parenchymal density (that may limit superior NAC slide and pedicle folding) should be considered when selecting a pedicle pattern. Despite the aforementioned principles of pedicle selection, anatomy frequently permits transposition of the nipple on a superior pedicle, even in larger reductions (>500 grams). The superomedial pedicle does not allow for sculpting of the medial pillar without concerns for vascular compromise to the nipple. Pillar sculpting is intrinsic to our described technique; therefore, the superior pedicle is selected when possible.
Scar revision was the most common complication and cause of secondary surgery in this series. Revision rates correlated with scar pattern, with strictly vertical pattern reductions requiring vertical limb dog-ear excision along the inframammary fold in up to 24.75% of patients. This rate exceeds that of the 11% to 20% scar revision rate quoted in other case series.18 In the early years of perfecting the technique, a concerted effort was made to gather the incision as a true vertical scar. Dissatisfied with high scar revision rates, the senior author frequently adapted a J, L, or short-T shaped skin excision pattern since 2007 (used in approximately 69% of patients in this series), lowering this revision rate to approximately 15% to 16%. Bunching of the vertical incision with closure is not practiced, as this can lead to wound healing complications. The “boxing” suture, described by Lista and Ahmad, is employed in mild cases of skin redundancy along the inframammary fold.7 Strictly vertical skin closures are reserved for smaller reductions (≤200 grams), or young women without striae or completely normal skin.
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Figure 13. (A, C) Preoperative and (B, D) 18 month postoperative views of a 24-year-old woman who underwent a small (350 gram) reduction.
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Rarely, if ever, do patients complain about a short-T scar, concealed within the inframammary fold. Despite the triviality of “dog-ear revision” in the eyes of the treating surgeon, the need for it may be considered a surgical failure in the eyes of the patient. Payor source was also examined with respect to complication rates following sculpted pillar vertical reduction mammaplasty. The only statistically significant difference in complication rates between cosmetic and insurance-based reduction mammaplasties related to rates of fat necrosis (0% vs 5%, respectively, P = .02). This is not surprising given knowledge that larger reductions predispose to increasing rates of fat necrosis.19 In general, cosmetic reductions were performed in large-breasted ectomorphic body types, while much larger-breasted endomorphic body types predominated in the insurance-based reduction population. The implied demographic in our insurance-based population was that they may have a higher BMI. All patients with Blue Cross Blue Shield of Alabama (the only carrier accepted at this practice) were required to have 500 gram reductions per side for the insurance carrier to be fiscally responsible for the procedure. Chun et al identified that a BMI cutoff of
approximately 35 predisposes to a significantly higher rate of complications in reduction mammaplasty.22
Vertical Sculpted Pillar Breast Reduction Patient Reported Outcomes Few outcomes-based studies, and even fewer randomized controlled trials, exist to guide surgeons’ technique selection for maximizing patient satisfaction and well-being following reduction mammaplasty.18,23-31 Publication of patient-reported outcomes studies that rely on validated, reliable questionnaires may help with reduction technique selection for younger surgeons just starting out, as well as more advanced surgeons looking for technique modifications. The BREAST-Q is currently the most valid and reliable instrument we have for the purposes of fulfilling this task.11,29,30,32 The BREAST-Q was administered to all 317 patients who met inclusion criteria for our study. Fifty-nine questionnaires were returned for analysis. Alreck and Settle, in their Survey Research Handbook, indicate that a response rate of 10% is considered “good,” and a response rate of 30% is considered “remarkable” for opt-in survey studies.32 Carty
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Figure 14. (A, C) Preoperative and (B, D) 13 month postoperative views of a 49-year-old woman who underwent a large (800 gram) reduction.
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Table 2. Complication Rate Reporting for Recent Large Scale Reports of Reduction Mammaplasty Author(s)
Year
Patients (P) or breasts (B)
Technique (scar pattern and/or pedicle pattern)
Complication rate reporting - per patient (P) or per breast (B)
Overall complication rate (%)
Poor scarring (%)
Fat or tissue necrosis (%)
Superficial wound dehiscence or delayed healing (%)
Breast asymmetry or revision (%)
Nipple asymmetry (%)
Hematoma or seroma (%)
Nipple sensory loss (%)
NAC necrosis (%)
Antony et al17
2013
100 (P)
VRM, 50 (P); WPIP, 50 (P)
B
N/A
N/A
N/A
8 (VRM); 10 (WPIP)
N/A
N/A
6 (VRM); 2 (WPIP)
11 (VRM); 13.5 (WPIP)
0 (VRM); 1 (WPIP)
Adham et al21
10
1.92
10
15
6.54
1.54
260 (P)
VRM
P
N/A
2011
2000 (B)
VRM
B
N/A
0.2
0
0.2
0.9
0.7
0.2
N/A
N/A
Lacotte34
2008
1200 (B)
VRM
B
N/A
N/A
N/A
9
N/A
N/A
8.5
N/A
0.2
Djemal35
2008
721 (P)
VRM
P
N/A
2.8
0
2.1
1.1
N/A
1.7
1.1
N/A
Zoumaras et al20
2008
191 (P)
VRM, 96 (P); WPIP, 95 (P)
B
N/A
N/A
6.2 (VRM); 4.2 (WPIP)
11.4 (VRM); 38.9 (WPIP)
N/A
0 (VRM); 1 (WPIP)
8.3 (VRM); 3.1 (WPIP) “hematoma only”
N/A
1 (VRM); 0 (WPIP)
Hofmann et al15
2007
500 (B)
VRM
B
N/A
N/A
1.8
4.8
N/A
N/A
5
N/A
N/A
2006
500 (B)
VRM
B
5.6
0.2
0.8
2.2
0.4
N/A
1.6
N/A
N/A
2006
103 (P)
VRM, 63 (P); WPIP, 40 (P)
P
N/A
6.3 (VRM); 0 (WPIP)
N/A
0 (VRM); 2.5 (WPIP)
N/A
N/A
0 (VRM); 2.5 (WPIP)
N/A
N/A
2005
518 (P)
WPIP
P
N/A
4.2
N/A
9.8
4.2
N/A
9.8
N/A
20.1
1994
192 (B)
VRM
B
N/A
N/A
2.1
2.1
N/A
N/A
5.2
N/A
N/A
Lassus
Lista et al
7
Spector et al
Scott et al36 Lejour
6
18
N/A, information not available or reported; NAC, nipple-areolar complex; VRM, vertical reduction mammaplasty; WPIP, Wise or inverted-T pattern inferior pedicle.
et al reviewed 26.1% of distributed, postoperative module BREAST-Q surveys (comparable to the return rate in this manuscript) and offered valuable insight that increased surgeon experience and efficiency do not equate to increased gains in patient satisfaction following breast reduction.29 Gonzalez et al found that neither amount of resected tissue, nor patient BMI, affected the degree of quality of life improvement following reduction mammaplasty. This plausible conclusion was obtained despite only 178 of their 600 distributed BREAST-Q surveys being returned (29.6% response rate).33 Breast reduction is generally considered to be a procedure with a high degree of patient satisfaction. Patient-reported outcomes studies are reflective of this claim.17-19,24-26,30 Some studies have aimed to identify differences, or lack thereof, in quality of life improvement between techniques.17,23 Rather than technique comparison, we specifically aimed to determine if postoperative BREAST-Q scale scores differed based on payor source (ie, cosmetic vs insurance-based). No statistically significant differences were noted between cosmetic (n = 16), and insurance-based (n = 43) patients in any scale of the postoperative BREAST-Q in this study. This finding further supports current evidence in the literature that BMI value and extent of parenchymal resection do not correlate with patient-reported outcomes. Insurance-based reductions in this study were typically performed in patients with higher BMI’s and larger resection tissue weights. This study has shown that cosmetic and insurance-based reduction mammaplasty patients experience equivalent rates of patient satisfaction in all postoperative domains of the
BREAST-Q. This information can be used to guide the preoperative consultation process for insurance-based patients who may be unaware that their satisfaction and well-being will likely equate to that of patients undergoing reduction mammaplasty solely for cosmetic purposes. This study was limited in its acquisition of only postoperative BREAST-Q modules, and the limited questionnaire return rate (19%). Pre and postoperative questionnaire administration would have been optimal for trend analysis, but due to the retrospective nature of this study, preoperative questionnaires were unable to be obtained. Studies of comparable design had similar response rates and offered results that were beneficial to the breast reduction literature.29,33 Cohort numbers were quite different between the superior and superomedial pedicle groups. Formal statistical analysis, and validation of statistical methodology, was performed under the direction of the Department Chair of Biostatistics at the University of Alabama at Birmingham, Dr Redden (our coauthor). We have made clear to classify this as a Level 4 study, common for this type of publication.
CONCLUSION This study intended to offer readers an easy to follow educational reference to facilitate incorporation of the vertical sculpted pillar breast reduction into their practices should they perceive the benefits this technique has provided the senior author over decades of patient care. Larger reductions, in which the superomedial pedicle was employed,
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2011
16
Derby et al
experienced increased rates of fat necrosis. This fact supports currently reported results, and should be shared with the patient preoperatively to appraise them of their increased risk if the superomedial pedicle must be used. Secondary surgery, most commonly due to dog-ear revision, is decreased when J, L-shaped, or short-T scar patterns are incorporated. A slightly longer scar is considered to be a small tradeoff when the need for surgical revision can be avoided. Knowing that cosmetic and insurance-based reductions fare equally as well on the postoperative BREAST-Q patient reported outcomes module may facilitate the preoperative consultation process.
13
7.
8. 9.
10. 11.
Supplementary Material
12.
This article contains supplementary material located online at www.aestheticsurgeryjournal.com.
13.
The authors would like to thank Ashley N. Derby, ACNP, and Katie Gothard, BS, for their invaluable contribution to data collection. The authors would also like to thank all former aesthetic surgery fellows of Grotting Plastic Surgery, each of whom were instrumental in refining the elements of this technique.
Disclosures Dr Grotting is a founder and shareholder of CosmetAssure (Montgomery, AL), an author for Quality Medical Publishing (St. Louis, MO) and Elsevier (New York, NY), and a shareholder of Keller Medical (Stuart, FL) and Ideal Implant (Dallas, TX). The other authors have nothing to disclose.
Funding The authors received no financial support for the research, authorship, and publication of this article.
REFERENCES 1.
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2014 Plastic Surgery Statistics Report. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. http:// www.plasticsurgery.org/Documents/news-resources/ statistics/2014-statistics/plastic-surgery-statsitics-fullreport.pdf. Accessed May 1, 2015. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002;22:208-217. Dieffenbach JF. Die operative chirurgerie. Vol. 2. Leipzig: Brockhaus. 1848. Courtiss EH, Goldwyn RM. Reduction mammolasty by the inferior pedicle technique. An alternative to free nipple and areola grafting for severe macromastia or extreme ptosis. Plast Reconstr Surg. 1977;59:500-507. Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg. 1996;97:373-380. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994;94:100-114.
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Acknowledgments
Lista F, Ahmad J. Vertical scar reduction mammaplasty: a 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg. 2006;117:2152-2165. Chiari A. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg. 1992;90:233-246. Hammond D. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg. 1999;103: 890-901. Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg. 1990;14:93-100. Chiari AC, Grotting JC. The L Short-scar Mammaplasty. In: Spear SL, ed. Surgery of the Breast Principles and Art. 3rd ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010:1128-1143. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124:345-353. Spear SL, Carter ME, Low M, Ducic I, Schwartz MS. Sickle cell trait: a risk factor for flap necrosis. Plast Reconstr Surg. 2003;112:697-698. Fischer JP, Cleveland EC, Shang EK, Nelson JA, Serletti JM. Complications following reduction mammaplasty: a review of 3538 cases from the 2005–2010 NSQIP data sets. Aesthet Surg J. 2014;34(1):66-73. Hofmann AK, Wuestner-Hofmann MC, Bassetto F, Scarpa CMazzoleni F. Breast reduction: modified "Lejour technique" in 500 large breasts. Plast Reconstr Surg. 2007;120: 1095-1104. Lassus C. The Lassus vertical technique. Aesthet Surg J. 2011;31(8):897-913. Antony AK, Yegiyants SS, Danielson KK, et al. A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years. Plast Reconstr Surg. 2013;132: 1068-1076. Spector JA, Kleinerman R, Culliford AT, Karp N. The vertical reduction mammaplasty: a prospective analysis of patient outcomes. Plast Reconstr Surg. 2006;117: 374-381. Daane SP, Rockwell WB. Breast reduction techniques and outcomes: a meta-analysis. Aesthet Surg J. 1999;19(4): 293-303. Zoumaras J, Lawrence J. Inverted-T versus vertical scar breast reduction: one surgeon’s 5-year experience with consecutive patients. Aesthet Surg J. 2008;28(5): 521-526. Adham M, Sawan K, Lovelace C, Jaeger NJ, Adham C. Unfavorable outcomes with vertical reduction mammaplasty: part II. Aesthet Surg J. 2011;31(1):40-46. Chun YS, Schwartz MA, Gu X, Lipsitz SR, Carty MJ. Body mass index as a predictor of postoperative complications in reduction mammaplasty. Plast Reconstr Surg. 2012;129: 228e-233e. Thoma A, Ignacy TA, Duku EK, et al. Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty. Plast Reconstr Surg. 2013;132:48e-60e.
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using a validated survey instrument: the BREAST-Q. Plast Reconstr Surg. 2013;132:285-290. Chadbourne EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammaplasty: a systematic review and meta-analysis of published studies. Mayo Clin Proc. 2001;76:503-510. Alreck PL, Settle RB, eds. The survey research handbook. 3rd ed. Boston, MA: McGraw-Hill;2003. Gonzalez MA, Glickman LT, Aladegbami B, Simpson RL. Quality of life after breast reduction surgery: a 10-year retrospective analysis using the Breast Q questionnaire: does breast size matter? Ann Plast Surg. 2012;69: 361-363. Lacotte B. From the inverted T scar to the vertical scar Lassus mammaplasty? Twenty-First Anniversary Meeting of the Mediterranean Society of Aesthetic Plastic Surgery, April 2008, Nice, France. Djemal T. Personal experience with the Lassus technique. Twenty-First Anniversary Meeting of the Mediterranean Society of Aesthetic Plastic Surgery, April 2008, Nice, France. Scott GR, Carson CL, Borah GL. Maximizing outcomes in breast reduction surgery: a review of 518 consecutive patients. Plast Reconstr Surg. 2005;116(6): 1633-1639.
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29.
Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg. 2005;115:1025-1031. O’Blenes CA, Delbridge CL, Miller BJ, Pantelis A, Morris SF. Prospective study of outcomes after reduction mammaplasty: long-term follow-up. Plast Reconstr Surg. 2006;117: 351-358. Neto MS, Abla LE, Lemos AL, et al. The impact of surgical treatment on the self-esteem of patients with breast hypertrophy, hypomastia, or breast asymmetry. Aesthetic Plast Surg. 2012;36:223-225. Adham M, Sawan K, Lovelace C, Zakhary J, Adham C. Patient satisfaction with vertical reduction mammaplasty: Part I. Aesthet Surg J. 2010;30(6):814-820. Breiting LB, Henriksen TF, Kalialis LV, Gramkow C. A prospective study of short- and long-term cosmetic outcome after reduction mammaplasty from three different perspectives: the patient, a department surgeon, and an independent private practitioner in plastic surgery. Plast Reconstr Surg. 2012;130:273-281. Carty MJ, Duclos A, Gu X, Elele N, Orgill D. Patient satisfaction and surgeon experience: a follow-up to the reduction mammaplasty learning curve study. Eplasty. 2012;12:e22. Coriddi M, Nadeau M, Taghizadeh M, Taylor A. Analysis of satisfaction and well-being following breast reduction
Breast Surgery
Vertical Sculpted Pillar Reduction Mammaplasty in 317 Patients: Technique, Complications, and BREAST-Q Outcomes
Aesthetic Surgery Journal 2016, 1–14 © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjv217 www.aestheticsurgeryjournal.com
Brian M. Derby, MD; James C. Grotting, MD, FACS; and David T. Redden, PhD
Level of Evidence: 4
Accepted for publication September 17, 2015. Reduction mammaplasty is a commonly performed surgical procedure. The American Society of Plastic Surgeons reported that 41,309 aesthetic breast reductions, and 59,883 reconstructive breast reductions, were performed in 2014.1 The objectives of reduction mammaplasty include gland resection, relocation of a ptotic nipple to a more anatomically aesthetic location, resection of skin excess, and provision of a durable, aesthetic breast shape. A variety of techniques exist for preservation of nipple blood supply, gland shaping, and skin redraping that facilitate preservation of aesthetic breast appearance after reduction surgery. Algorithms have been provided to delineate those seeking the procedure primarily out of medical necessity for relief of upper back/neck/shoulder/arm pain, rashes, grooving, and
Therapeutic
Dr Derby is a plastic surgeon in private practice in Sarasota, FL. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; a Clinical Professor, Division of Plastic and Reconstructive Surgery, University of Wisconsin, Madison, WI; and is the CME/MOC Section Editor for Aesthetic Surgery Journal. Dr Redden is the Chair, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL. Corresponding Author: Dr James C. Grotting, Grotting and Cohn Plastic Surgery, 1 Inverness Center Parkway, Suite 100, Birmingham, AL 35242, USA. E-mail: [email protected] Presented at: the 58th Annual Scientific Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons in Amelia Island, FL in June 2015.
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Abstract Background: The senior author (JCG) has described the vertical sculpted pillar breast reduction. Objectives: This manuscript aimed to compare this technique’s safety profile to other established techniques via complication rate reporting. Few studies have utilized the BREAST-Q for long-term outcomes reporting in bilateral reduction mammaplasty patients. BREAST-Q outcome comparisons, between cosmetic and insurance-based breast reduction cohorts, have not been previously reported. Methods: A retrospective chart review was performed on patients who underwent reduction mammaplasty using the vertical sculpted pillar technique. The BREAST-Q postoperative reduction mammaplasty module was administered. Complication rates and outcomes data were compared among patient cohorts distinguished by pedicle, scar pattern, and payor population. Statistically significant differences were set at P < .05. Results: Compared to the superior pedicle, use of the superomedial pedicle statistically increased rates of postoperative fat necrosis in this series. Complication rates did not differ among scar patterns, but use of a J, L-shaped, or short-T scar decreased the need for secondary/revisional surgery. Cosmetic and insurance-based outcomes did not differ in any domain of the postoperative reduction mammaplasty BREAST-Q module. Conclusions: Complications data for the vertical sculpted pillar reduction mammaplasty were comparable to published results for other techniques. Complication rates are unaffected by scar pattern. Superomedial pedicle selection and larger insurance-based reductions may predispose to statistically significant increases in fat necrosis compared to use of the superior pedicle. Payor source neither affects the majority of complication rates, nor BREAST-Q satisfaction and quality of life domains. This information can be used to improve management of expectations during the preoperative consultation process.
2
METHODS A retrospective chart review was performed on a series of insurance and cosmetic primary bilateral breast reduction mammaplasty patients who underwent the vertical sculpted pillar reduction mammaplasty by the senior author from February 2003 to May 2015. Inclusion criteria included female patients undergoing primary bilateral reduction mammaplasty. Exclusion criteria included: male gender, unilateral reduction mammaplasty, prior history of breast reconstruction, and/or a personal history of breast surgery (ie, lumpectomy, reduction
mammaplasty, augmentation mammaplasty, mastopexy). The inclusion/exclusion criteria were established to ensure that the postoperative reduction mammaplasty BREAST-Q reporting module was administered to a homogeneous cohort of primary reduction mammaplasty patients. Three hundred and eighty-six (386) patients were identified as possible candidates for inclusion after an electronic medical record search using the keywords “reduction mammaplasty” and “breast reduction.” Of these, 317 patients met inclusion criteria. Variables such as patient age, height, weight, body mass index (BMI), smoking history, weight of reduction specimens, superior or superomedial pedicle usage, scar pattern, and complications were extracted, and entered into a Microsoft Excel (Microsoft, Inc. Redmond, WA) data acquisition spreadsheet. Complications included seroma/hematoma, fat necrosis, nipple-areolar complex (NAC) necrosis, skin loss, scar revision, and breast dehiscence. Total and specific complication rates were tabulated and compared statistically with respect to scar pattern, pedicle, and payor source (cosmetic vs insurance-based). Patients were also provided with the postoperative BREAST-Q reduction mammaplasty module, a validated patient-reported survey for breast outcomes studies.12 The BREAST-Q was administered at an average 73 months (6.1 years) postoperatively. Personal correspondence with Amy Alderman, MD, has confirmed the validity of BREAST-Q outcomes study at 6 years postoperatively. Dr Alderman has been instrumental in the development of outcomesbased study within our field. Outcomes data were tabulated, summarized, and statistically analyzed. Statistical analyses began by calculating measures of central tendency (sample mean, sample medians) and dispersion (variance, standard deviation) for continuous outcomes by group (cosmetic, insurance, superomedial, superior). Categorical variables were summarized as sample proportions by group. To test for mean differences between groups on continuous outcomes, two-sample t test were conducted. To test for differences in proportions, chi-square analyses were conducted. Careful attention was given to all statistical assumptions for these procedures and to gauge sensitivity to these assumptions, non-parametric procedures (Wilcoxon Rank Sum) for continuous outcomes and Fisher’s exact test for proportions were also conducted. Given all approaches generated identical inferences, we have chosen to report the two-sample t tests and chi-square analyses. All analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC) with a Type I error rate of 0.05. Patients were provided with, and signed, informed consent for use of their personal health information utilized in this review. Institutional Review Board approval was obtained from the University of Alabama at Birmingham (Protocol #X141016001).
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numbness vs those desiring aesthetic improvement alone.2 While symptom alleviation is important, one’s choice of technique should provide the patient with a long-lasting, aesthetic result. From Dieffenbach’s first account of reduction mammaplasty in a woman,3 it has been evident that every technique has its limitations and advantages.4-10 Pillar sculpting became popularized by Armando Chiari Jr., who also emphasized the concept incorporated into every reduction mammaplasty performed in this practice – what is most important in a reduction mammaplasty is the tissue left behind, not that resected.8,11 It was the senior author’s (JCG) personal experience with Dr Chiari that prompted the integration of pillar sculpting into the presented reduction technique to maximize conical shaping of the breast. The aim of this manuscript is to demonstrate how the positive attributes of the more commonly practiced reduction techniques have been distilled down, and combined into a procedure that the senior author has entitled vertical sculpted pillar reduction mammaplasty. The technique narrows the breast base, empties the lower pole of the breast along a central and inferomedial/lateral Wise pattern parenchymal resection, bases the nipple on a superior or superomedial well-vascularized pedicle, and offers a shorter scar. Pillars are sculpted such that they narrow the breast and obliterate dead space when brought together like the pages of an open book, and deproject the breast when their resected concave bases rest upon the convexity of the chest wall. These efforts are intended to provide a very pleasing, durable, conical breast shape through “sculpting” maneuvers. This manuscript also aims to provide the reader with a descriptive technique reference to facilitate incorporation of the vertical sculpted pillar breast reduction into their practice should they recognize the benefits this technique has provided the senior author over the last twelve years with hundreds of patients. It is an easy technique to teach and comprehend. Finally, this manuscript aims to add to the growing body of standardized patient-reported outcomes data through the postoperative administration of the BREAST-Q to a series of patients.
Aesthetic Surgery Journal
Derby et al
Operative Technique Preoperative Markings
from the 6 o’clock position of the areolar marking. A Wise-pattern parenchymal resection is then marked obliquely from the inferior aspect of each vertical pillar marking, and drawn to meet the inframammary fold. The vertical limb markings are joined inferiorly in an elliptical fashion, approximately 2 to 3 cm above the inframammary fold. Areas of anticipated axillary liposuction are marked for lateral breast border definition. The most caudal portion of the superior pedicle is then marked inferior to the NAC, sparing only 1 to 2 cm inferior to the NAC as this tissue does not contribute to blood supply (Figure 3). A video demonstrating the preoperative markings is available as Supplementary Material at www. aestheticsurgeryjournal.com.
Intraoperative Details Local anesthetic (0.5% lidocaine with epinephrine [1:200,000]) is infiltrated in a standardized, sequential manner to facilitate relatively bloodless pedicle de-epithelialization, parenchymal resection, and pillar development. We have found the most effective area to infiltrate, to minimize intraoperative bleeding, is the plane between the gland and pectoralis muscle.
Subglandular Undermining. Attention is then turned towards deepening the incision, inferior to the base of the pillars, within the level of the mastectomy plane down to the chest wall. The central parenchymal tissue is then elevated off of the chest wall in the subglandular plane. The surgeon should exercise caution at this point, as it is easy to enter the subpectoral plane. Dissection is carried to the level of the anterior branch of the fifth intercostal perforator, which has been found to be universally present. Once this vessel is
Figure 1. Creating the lateral breast contour, as demonstrated on a 21-year-old woman. Firm medial traction atop the breast is aimed at creating the most pleasing lateral breast contour possible prior to incising along the pillar.
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The patient is marked in the standing position with the surgeon seated in front of her. The sternal notch and abdominal midline are marked. Evidence of scoliosis, shoulder height asymmetries, discrepancies in breast width/volume, and dissimilarities in nipple position may be identified at this time. The inframammary fold is marked. The chest wall meridian, breast meridian, and superior margin of the breast mound are then marked. From anecdotal discussions with Dr Elizabeth Hall-Findlay, the superior breast border can be identified by observation of the upper chest wall crease formed with gentle superior pressure applied to the inferior pole of the breast. To identify the new position of the NAC, the surgeon’s fingertips are placed at the inframammary fold, and the breast is allowed to drape atop the fingertips. The location of the fingertips is transposed to the anterior surface of the breast, and a small transverse marking is made perpendicular to the breast meridian at the corresponding location (the A point of Pitanguy). This mark identifies the future location of the superior margin of the areola, not the nipple, and ideally lies 10 cm inferior to the previously marked superior border of the breast mound. Care must be taken to confirm that this new nipple position lies at the most projecting part of the simulated reduction/lift by pinching the breast skin with both hands using the Lassus maneuver (see description below). The medial and lateral vertical limbs/pillars of the vertical reduction pattern are then marked with a gentle, but firm, lateral and medial displacement of the breast. Markings are made in line with the chest wall meridian. Focusing on the amount of skin and breast tissue to be left behind with this maneuver ensures aesthetic breast shaping upon pillar and skin closure. This concept becomes particularly apparent with medial displacement of the breast, when attention is directed towards marking the future location of the lateral vertical limb/pillar that creates the most pleasing lateral breast contour (Figure 1). Attention is then directed towards ensuring that the new NAC position correlates with the most projecting part of the simulated reduced breast mound. Using the Lassus maneuver the surgeon’s fingertips straddle the two vertical limb markings, followed by a centrally directed pinch at the anticipated 6 o’clock position of the NAC for the reduced breast (Figure 2). This move simulates closure of the new areolar circumference. The desired locations of the 6 o’clock areolar position are marked transversely, crossing perpendicularly through the superior aspect of the vertical limb markings. The areolar circumference is then marked freehand, often measuring 14 to 15 cm in length. The heights of the medial and lateral pillars are then marked along the vertical limbs, typically measuring 6 cm
3
4
Aesthetic Surgery Journal
Figure 3. Completed markings demonstrated on a 21-year-old woman. Markings are photographed and kept as part of the patient record.
divided, the remainder of the superocentral dissection is performed bluntly to a level corresponding with the marked superior extent of the breast mound.
mammaplasty technique is available as Supplementary Material at www.aestheticsurgeryjournal.com.
Pillar Height Sculpting. A sponge is then inserted into the centrally dissected tunnel. At this point, one’s attention is turned towards resection of the central gland between the medial and lateral pillars. It is important to conceptualize the pillars coming together like the pages of an open book after central gland resection. Rather than incising perpendicularly from skin to chest wall along the vertical limbs, we prefer to angle the blade medially for the lateral dissection, and laterally for the medial dissection. This blade angle helps sculpt the inner aspect of each pillar like the pages of a large open book, and eliminates dead space upon pillar approximation. The lower border of the pedicle is then incised to a thickness of 2 cm. The resection is carried superiorly to a level halfway between the nipple and the upper border of the breast, and then transitioned into a Pitanguy/keel-shaped excision deep to the superior pole. The margins of the keel excision are made in line with the inner aspect of each pillar incision. Aggressive superior pole tissue resection is avoided in order to maintain fullness (Figure 4). A video demonstrating the vertical sculpted pillar reduction
Pillar Base Sculpting. The pedicle is retracted anteriorly off of the chest wall. A measurement of 6 cm is typically made from the 6 o’clock position of the areola. In taller individuals, with longer chest walls, this measurement can be made at 7 cm to more appropriately fit breast projections in taller frames. It is important to conceptualize creating a pillar shape and height that is proportional to the chest wall. The pillar base must be resected so that the breast is deprojected. A ruler is held flush against the inner aspect of the lateral pillar. The new base of the pillar is marked with methylene blue, taking origin from the previously marked Wise-pattern skin marking on the breast surface, and then continuing across the base so that the height of the pillar is 6 to 7 cm (6 cm in smaller reductions/pexies, 7 cm in larger reductions) (Figure 5). Prior to incising this marking, one should consider the objective of sculpting the pillar base in a concave manner such that it rests anatomically upon the convex chest wall. A 10-blade scalpel is passed from medial to lateral, deeply through the pillar base methylene blue marking, and is then redirected to pass from lateral to medial as the excess parenchymal tissue is resected from
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Figure 2. The Lassus maneuver demonstrated on a 21-year-old woman. Using the Lassus maneuver the surgeon’s fingertips straddle the two vertical limb markings, followed by a centrally directed pinch at the anticipated 6 o’clock position of the NAC for the reduced breast.
Derby et al
5
Dressing and Postoperative Care. The dressing mainFigure 4. Medial and lateral pillars after gland excision demonstrated on a 21-year-old woman. The central parenchymal resection between the pillars is appreciated. Wise pattern parenchymal excision has also been performed.
the overlying skin flap. The laterally to medially directed blade minimizes potential injury to the sensory nerve supply entering the lateral pillar. A similar technique is employed for medial pillar base sculpting, but conservative resection is encouraged in order to preserve medial breast bulk. Hemostasis is then obtained (Figure 6).
Marchac Suture, Pillar Approximation, and Lateral Breast Border Liposuction. Anterior retraction on the Adair clamps lines up the pillars for approximation. The Marchac suture is placed prior to pillar approximation, and greatly facilitates superior pole shaping. This suture technique incorporates a 2-0 polyglactin suture passed from the undersurface of the superior gland to the chest wall, as high as possible, to accentuate the roundness of the upper pole. Pillar approximation is then performed. A key 2-0 polyglactin suture is placed through the deep dermis and
tains shapely superomedial breast position afforded by the vertical sculpted pillar technique. Two large, transparent adhesive dressings are applied. They are draped across the breast from lateral to medial, first across the lower pole, and subsequently across the upper pole. The concept is to hold the breast position into the desired shape and position. Care must be taken not to attempt to apply tension to the dressing during placement, as this may result in postoperative skin blistering. A small window is made for the nipple, and a surgical bra is applied. The patient returns to clinic at one week, at which point a larger periareolar window is cut, and areola cleansed. The transparent dressing and nylon sutures are removed at two weeks. The patient may shower on postoperative day one. Antibiotics are continued postoperatively for one week.
RESULTS Patient Demographics The average patient age at the time of surgery was 39.6 years (range, 14-76 years). Average BMI was 28.5 kg/m2 (range, 18.5-46 kg/m2). Patients were followed clinically for an
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superficial fascia at the 6 o’clock areolar position. Pillars are then approximated from superior to inferior, effectively narrowing the breast (Figure 7). Areolar and vertical limb skin is then tailor-tacked. Redundant skin may remain inferiorly, and can be excised in a small J or inverted-T shaped pattern if necessary. Attention is directed towards the lateral breast border. The gentle lateral curve, created by pillar sculpting and approximation, can be appreciated. The curve should be followed to the level of the newly elevated inframammary fold, but is often noted to remain blunted inferolaterally. To enhance the inferolateral pole curvature, another key suture of 2-0 polyglactin suture is placed. This passes from the underside of the gland/lateral pillar base at the level of the new inframammary fold, and then through the pectoralis fascia, typically at the chest meridian. Immediate contouring of the inferolateral breast curvature can be appreciated (Figure 8). Tumescent infiltration (120 mL of 1 L lactated ringer’s/1 ampule of epinephrine/30 mL of 1% lidocaine) followed by suction-assisted lipoplasty offers final aesthetic contouring of the lateral chest wall. We have found that performing the liposuction prior to placement of the lateral pillarshaping suture can be advantageous as it minimizes risk of disrupting this suture with repeated passages of the liposuction cannula. A drain is only used when extensive liposuction is performed. Skin is then closed in standard fashion.
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Figure 6. Lateral sculpted pillar resting upon the chest wall demonstrated on a 21-year-old woman. The 6 cm pillar will rest upon the chest wall, effectively deprojecting the breast after pillar base resection.
average of 11.9 months (range, 0.5-93 months). Reduction specimen weight averaged 566 grams on the left (range, 25-2038 grams), and 540 grams on the right (range, 25-1853 grams), for a total average resection weight of 1106 grams (range, 50-2959 grams). Postoperative BREAST-Q reduction mammaplasty modules were returned for 59 of 317 patients, for a return rate of 18.6%. The questionnaire was administered at an average of 73 months (6.1 years) postoperatively.
Intraoperative Details Scar patterns were reportable for all 317 patients: short-T (51%), J or L-scar (17%), or vertical (32%). A superior pedicle was used in 83% of patients, and a superomedial pedicle was used in 17% of patients (Table 1).
Complication Rates Based on Pedicle Pattern
Figure 7. Pillar approximation demonstrated on a 21-year-old woman. Pillar bases are approximated to narrow the breast.
Superior (n = 262 patients) and superomedial (n = 55 patients) pedicles were compared with respect to postoperative rates of dehiscence, dog-ear or scar revision, fat necrosis, skin loss, hematoma, NAC loss, and secondary surgery. Statistically significant differences were noted between superior and superomedial pedicles for rates of fat necrosis (2.29% vs 9.09%, respectively, P = .02) (Figure 9).
Dog-ear/scar revision rates were 19.08% and 14.55% for superior and superomedial pedicles, respectively, but these differences were not statistically significant. NAC loss and dehiscence rates trended towards more commonly occurring in patients with superomedial pedicle reductions,
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Figure 5. Measuring the pillar height at 6 cm demonstrated on a 21-year-old woman. The ruler is held flush against the face of the lateral pillar from the planned 6 o’clock areolar margin. Pillar height is marked at 6 cm.
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but one must consider that the two nipple losses in the superomedial group occurred in the same patient who underwent reduction mammaplasty with a history of sicklecell trait. She suffered nipple loss at two weeks, comparable to the presentation of nipple necrosis previously reported in the literature in this same patient population.13 While inclusion of the sickle-cell trait patient may inherently skew data, exclusion of any patient who met inclusion criteria for this review may be considered selection bias. It is our hope that by raising awareness of this complication in the patient with sickle-cell trait, we may potentially help other surgeons avoid a similar outcome with a similar patient in their own practice. The superomedial pedicle remains a safe and reliable vascular supply to the nipple in reduction mammaplasty.
Complication Rates Based on Scar Pattern Short-T, J, or L-shaped, and vertical scar patterns were compared with respect to postoperative complication rates for dehiscence, dog-ear or scar revision, fat necrosis, skin loss, hematoma, NAC loss, and secondary surgery. No statistically significant differences in complication rates were noted among the three scar patterns employed intraoperatively (Figure 10).
Complication Rates Based on Payor Source Cosmetic and insurance-based reductions were compared with respect to postoperative complication rates for dehiscence, dog-ear or scar revision, fat necrosis, skin loss,
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Figure 8. Lateral shaping suture demonstrated on a 21-year-old woman. The lateral shaping suture is placed from the base of the lateral pillar to the chest wall fascia at the level of the newly elevated inframammary fold. The suture enhances the inferolateral curvature of the breast. (A, B) Inferior views before and after suture placement. (C, D) Anterior views before and after suture placement.
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hematoma, NAC loss, and secondary surgery. A statistically significant increase in fat necrosis was found for insurancebased breast reduction patients. Payor source did not contribute to differences in rates of occurrence of other reported complications (Figure 11).
Table 1. Patient Demographics
Age (years) 2
Mean ± SD
Range
39.6 ± 14.6
14-76
BMI (kg/m )
28.5 ± 5.5
18.5-46
Clinical follow-up (months)
11.9 ± 12.5
0.5-93
BREAST-Q Scores Based on Payor Source BREAST-Q scores were tabulated for all satisfaction and quality of life (or well-being) scales assessed by the postoperative reduction mammaplasty questionnaire module. Satisfaction scales assessed patients’ postoperative satisfaction with their breasts, overall outcome, nipples, information (about risks, healing, recovery time, details of procedure), plastic surgeon, medical staff, and office staff. Quality of life (or well-being) scales assessed patients’ postoperative psychosocial, sexual, and physical well-being. No statistically significant differences in patient-reported outcomes scales were noted between cosmetic and insurance-based reduction mammaplasty patients (Figure 12).
DISCUSSION
Resection weight (grams) 539.9 ± 293.4
25-1853
Left
566.2 ± 297.2
25-2038
% (n) Pedicle Type Superior
83% (262)
Superomedial
17% (55)
Scar Pattern Short-T
51% (162)
Vertical
32% (100)
J or L
17% (55)
Payor Insurance
69% (220)
Cosmetic
31% (97)
BMI, body mass index; n, number of patients; SD, standard deviation.
Figure 9. Complication rates based on pedicle pattern. A statistically significant difference in complication rates, between the superior and superomedial pedicle, was only seen for fat necrosis.
This manuscript does not advocate for a “better” technique of reduction mammaplasty, as the literature is replete with over 70 technical variations for reduction mammaplasty that work best in various authors’ hands. The “best” technique is the technique that produces few complications and consistently satisfied patients in one’s hands. The aim, instead, was to offer a transparent review of complications and patient-reported outcomes with a technique considered to be an amalgam of principles derived from personal influences, and decades of experience reducing and “sculpting” breast tissue to produce a long-lasting, aesthetic breast shape (Figures 13 and 14, Supplemental Figures S1 and S2).
Sculpted Vertical Pillar Breast Reduction Complications With no prospective randomized controlled trials available on the topic of reduction technique selection, and associated complication rates, surgeons are left to consolidate complications data from level III, or lower, large-scale case series
Figure 10. Complication rates based on scar pattern. No statistically significant differences in complication rates were noted among the scar patterns utilized in this series.
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Right
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Figure 12. BREAST-Q scores based on payor source. No statistically significant differences in patients’ postoperative wellbeing or satisfaction were seen between cosmetic and insurance-based reduction mammaplasties.
when assessing safety of his/her chosen technique.5-7,14-18 The largest review to date, from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database of 3538 breast reduction patients, identified that the risk-adjusted 30-day incidence of any postoperative complication was 5.1%, and that the incidence of major complications (ie, deep infection or return trip to the operating room) was 2.1%.14 Table 2 reports the complication rates for several, recent large scale series of breast reduction and serves as a consolidated reference for the reader. Daane and Rockwell report that complication rates range from 6.5% to 22% in their meta-analysis of five classical reduction mammaplasty techniques. 19 This manuscript sought to uncover potential relationships between complications and pedicle selection, scar pattern, and payor source following sculpted pillar vertical reduction mammaplasty. Lista and Ahmad offer that overall complication rates are higher in medial pedicle vertical reductions compared to superior pedicle vertical reductions (7% vs 5.3% of breasts).7 Antony et al performed a similar, but retrospective, comparison of a prospectively maintained database of vertical and inverted-T reduction mammaplasties.17 The metrics of complication rate reporting vary widely in the literature. Reports cite both “rates per patient” and “rates per breast,” making retrospective or prospective comparison of reported complication rate averages difficult to interpret (Table 2). Superomedial pedicle selection had a statistically significant impact on the incidence of fat necrosis in this series of 317 patients (Figure 9). Trends towards increased incidences of NAC loss and superficial wound dehiscence were also noted with use of the superomedial pedicle (3.64% and 5.45%, respectively, n = 55 patients). The superomedial pedicle was the pedicle of choice in patients with larger reductions – patients who also have higher incidences of fat necrosis. Fat necrosis reportedly occurs
with an incidence of 0.8% to 16% following reduction mammaplasty, depending on reduction size.19 “Per patient” complication rate reporting demonstrates a trend towards higher rates than “per breast” reports.7,15,18,20,21 Despite a 2.29% to 9.09% incidence (per patient) of fat necrosis in this series, no patient required a return trip to the operating room for excision of necrotic fat. Expectant management and massage, over the course of the first postoperative year, led to resolution of focal areas of postoperative parenchymal density. We consider the definition of fat necrosis to be one of palpable breast tissue firmness in the first year following breast reduction surgery. The most definitive way to determine its presence is excision with pathologic diagnosis. We do not typically suggest imaging or biopsy to our breast reduction patients in the absence of pain or skin distortion prior to 9 months postoperatively. Furthermore, in the cosmetic patient population, insurance coverage of the imaging study would likely be an issue. We possibly attribute the increased NAC loss and wound dehiscence rates, seen with superomedial pedicle reductions in this series, to implementation of this pedicle in larger, more ptotic reductions. The same etiology of increased fat necrosis (ie, decreased blood flow due to more extensive parenchymal resection) may have contributed to higher rates of NAC necrosis and wound dehiscence. We make no implication that the superomedial pedicle is a “less safe” pedicle. The literature is replete with its use and the safe, reliable, aesthetically pleasing results it provides for patients who undergo reduction mammaplasty. The superomedial pedicle does not lend itself as well to our technique of pillar sculpting. One cannot resect/sculpt the base of a superomedial pedicle without comprising blood supply. Through experience, we feel the superomedial pedicle should never be thinned nor undermined. Similar to Lista and Ahmad’s recommendation, the selection of a superior or (supero)medial pedicle is dictated
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Figure 11. Complication rates based on payor source. A statistically significant difference in complication rates, between cosmetic and insurance-based reduction mammaplasties, was only seen for fat necrosis.
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by nipple position relative to the mosque dome.7 When the NAC is below the mosque, a superomedial pedicle is selected to permit a more tension free rotation of the pedicle into position upon pillar closure. While this recommendation intends to minimize risk of pedicle compression in the presence of excessive pedicle length,16 density of breast parenchyma may also be a contributing factor to pedicle compression during NAC inset. Dense parenchyma may compromise NAC blood flow during inset of a superior pedicle. Therefore, preoperatively, extent of desired NAC elevation and parenchymal density (that may limit superior NAC slide and pedicle folding) should be considered when selecting a pedicle pattern. Despite the aforementioned principles of pedicle selection, anatomy frequently permits transposition of the nipple on a superior pedicle, even in larger reductions (>500 grams). The superomedial pedicle does not allow for sculpting of the medial pillar without concerns for vascular compromise to the nipple. Pillar sculpting is intrinsic to our described technique; therefore, the superior pedicle is selected when possible.
Scar revision was the most common complication and cause of secondary surgery in this series. Revision rates correlated with scar pattern, with strictly vertical pattern reductions requiring vertical limb dog-ear excision along the inframammary fold in up to 24.75% of patients. This rate exceeds that of the 11% to 20% scar revision rate quoted in other case series.18 In the early years of perfecting the technique, a concerted effort was made to gather the incision as a true vertical scar. Dissatisfied with high scar revision rates, the senior author frequently adapted a J, L, or short-T shaped skin excision pattern since 2007 (used in approximately 69% of patients in this series), lowering this revision rate to approximately 15% to 16%. Bunching of the vertical incision with closure is not practiced, as this can lead to wound healing complications. The “boxing” suture, described by Lista and Ahmad, is employed in mild cases of skin redundancy along the inframammary fold.7 Strictly vertical skin closures are reserved for smaller reductions (≤200 grams), or young women without striae or completely normal skin.
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Figure 13. (A, C) Preoperative and (B, D) 18 month postoperative views of a 24-year-old woman who underwent a small (350 gram) reduction.
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Rarely, if ever, do patients complain about a short-T scar, concealed within the inframammary fold. Despite the triviality of “dog-ear revision” in the eyes of the treating surgeon, the need for it may be considered a surgical failure in the eyes of the patient. Payor source was also examined with respect to complication rates following sculpted pillar vertical reduction mammaplasty. The only statistically significant difference in complication rates between cosmetic and insurance-based reduction mammaplasties related to rates of fat necrosis (0% vs 5%, respectively, P = .02). This is not surprising given knowledge that larger reductions predispose to increasing rates of fat necrosis.19 In general, cosmetic reductions were performed in large-breasted ectomorphic body types, while much larger-breasted endomorphic body types predominated in the insurance-based reduction population. The implied demographic in our insurance-based population was that they may have a higher BMI. All patients with Blue Cross Blue Shield of Alabama (the only carrier accepted at this practice) were required to have 500 gram reductions per side for the insurance carrier to be fiscally responsible for the procedure. Chun et al identified that a BMI cutoff of
approximately 35 predisposes to a significantly higher rate of complications in reduction mammaplasty.22
Vertical Sculpted Pillar Breast Reduction Patient Reported Outcomes Few outcomes-based studies, and even fewer randomized controlled trials, exist to guide surgeons’ technique selection for maximizing patient satisfaction and well-being following reduction mammaplasty.18,23-31 Publication of patient-reported outcomes studies that rely on validated, reliable questionnaires may help with reduction technique selection for younger surgeons just starting out, as well as more advanced surgeons looking for technique modifications. The BREAST-Q is currently the most valid and reliable instrument we have for the purposes of fulfilling this task.11,29,30,32 The BREAST-Q was administered to all 317 patients who met inclusion criteria for our study. Fifty-nine questionnaires were returned for analysis. Alreck and Settle, in their Survey Research Handbook, indicate that a response rate of 10% is considered “good,” and a response rate of 30% is considered “remarkable” for opt-in survey studies.32 Carty
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Figure 14. (A, C) Preoperative and (B, D) 13 month postoperative views of a 49-year-old woman who underwent a large (800 gram) reduction.
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Table 2. Complication Rate Reporting for Recent Large Scale Reports of Reduction Mammaplasty Author(s)
Year
Patients (P) or breasts (B)
Technique (scar pattern and/or pedicle pattern)
Complication rate reporting - per patient (P) or per breast (B)
Overall complication rate (%)
Poor scarring (%)
Fat or tissue necrosis (%)
Superficial wound dehiscence or delayed healing (%)
Breast asymmetry or revision (%)
Nipple asymmetry (%)
Hematoma or seroma (%)
Nipple sensory loss (%)
NAC necrosis (%)
Antony et al17
2013
100 (P)
VRM, 50 (P); WPIP, 50 (P)
B
N/A
N/A
N/A
8 (VRM); 10 (WPIP)
N/A
N/A
6 (VRM); 2 (WPIP)
11 (VRM); 13.5 (WPIP)
0 (VRM); 1 (WPIP)
Adham et al21
10
1.92
10
15
6.54
1.54
260 (P)
VRM
P
N/A
2011
2000 (B)
VRM
B
N/A
0.2
0
0.2
0.9
0.7
0.2
N/A
N/A
Lacotte34
2008
1200 (B)
VRM
B
N/A
N/A
N/A
9
N/A
N/A
8.5
N/A
0.2
Djemal35
2008
721 (P)
VRM
P
N/A
2.8
0
2.1
1.1
N/A
1.7
1.1
N/A
Zoumaras et al20
2008
191 (P)
VRM, 96 (P); WPIP, 95 (P)
B
N/A
N/A
6.2 (VRM); 4.2 (WPIP)
11.4 (VRM); 38.9 (WPIP)
N/A
0 (VRM); 1 (WPIP)
8.3 (VRM); 3.1 (WPIP) “hematoma only”
N/A
1 (VRM); 0 (WPIP)
Hofmann et al15
2007
500 (B)
VRM
B
N/A
N/A
1.8
4.8
N/A
N/A
5
N/A
N/A
2006
500 (B)
VRM
B
5.6
0.2
0.8
2.2
0.4
N/A
1.6
N/A
N/A
2006
103 (P)
VRM, 63 (P); WPIP, 40 (P)
P
N/A
6.3 (VRM); 0 (WPIP)
N/A
0 (VRM); 2.5 (WPIP)
N/A
N/A
0 (VRM); 2.5 (WPIP)
N/A
N/A
2005
518 (P)
WPIP
P
N/A
4.2
N/A
9.8
4.2
N/A
9.8
N/A
20.1
1994
192 (B)
VRM
B
N/A
N/A
2.1
2.1
N/A
N/A
5.2
N/A
N/A
Lassus
Lista et al
7
Spector et al
Scott et al36 Lejour
6
18
N/A, information not available or reported; NAC, nipple-areolar complex; VRM, vertical reduction mammaplasty; WPIP, Wise or inverted-T pattern inferior pedicle.
et al reviewed 26.1% of distributed, postoperative module BREAST-Q surveys (comparable to the return rate in this manuscript) and offered valuable insight that increased surgeon experience and efficiency do not equate to increased gains in patient satisfaction following breast reduction.29 Gonzalez et al found that neither amount of resected tissue, nor patient BMI, affected the degree of quality of life improvement following reduction mammaplasty. This plausible conclusion was obtained despite only 178 of their 600 distributed BREAST-Q surveys being returned (29.6% response rate).33 Breast reduction is generally considered to be a procedure with a high degree of patient satisfaction. Patient-reported outcomes studies are reflective of this claim.17-19,24-26,30 Some studies have aimed to identify differences, or lack thereof, in quality of life improvement between techniques.17,23 Rather than technique comparison, we specifically aimed to determine if postoperative BREAST-Q scale scores differed based on payor source (ie, cosmetic vs insurance-based). No statistically significant differences were noted between cosmetic (n = 16), and insurance-based (n = 43) patients in any scale of the postoperative BREAST-Q in this study. This finding further supports current evidence in the literature that BMI value and extent of parenchymal resection do not correlate with patient-reported outcomes. Insurance-based reductions in this study were typically performed in patients with higher BMI’s and larger resection tissue weights. This study has shown that cosmetic and insurance-based reduction mammaplasty patients experience equivalent rates of patient satisfaction in all postoperative domains of the
BREAST-Q. This information can be used to guide the preoperative consultation process for insurance-based patients who may be unaware that their satisfaction and well-being will likely equate to that of patients undergoing reduction mammaplasty solely for cosmetic purposes. This study was limited in its acquisition of only postoperative BREAST-Q modules, and the limited questionnaire return rate (19%). Pre and postoperative questionnaire administration would have been optimal for trend analysis, but due to the retrospective nature of this study, preoperative questionnaires were unable to be obtained. Studies of comparable design had similar response rates and offered results that were beneficial to the breast reduction literature.29,33 Cohort numbers were quite different between the superior and superomedial pedicle groups. Formal statistical analysis, and validation of statistical methodology, was performed under the direction of the Department Chair of Biostatistics at the University of Alabama at Birmingham, Dr Redden (our coauthor). We have made clear to classify this as a Level 4 study, common for this type of publication.
CONCLUSION This study intended to offer readers an easy to follow educational reference to facilitate incorporation of the vertical sculpted pillar breast reduction into their practices should they perceive the benefits this technique has provided the senior author over decades of patient care. Larger reductions, in which the superomedial pedicle was employed,
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2011
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experienced increased rates of fat necrosis. This fact supports currently reported results, and should be shared with the patient preoperatively to appraise them of their increased risk if the superomedial pedicle must be used. Secondary surgery, most commonly due to dog-ear revision, is decreased when J, L-shaped, or short-T scar patterns are incorporated. A slightly longer scar is considered to be a small tradeoff when the need for surgical revision can be avoided. Knowing that cosmetic and insurance-based reductions fare equally as well on the postoperative BREAST-Q patient reported outcomes module may facilitate the preoperative consultation process.
13
7.
8. 9.
10. 11.
Supplementary Material
12.
This article contains supplementary material located online at www.aestheticsurgeryjournal.com.
13.
The authors would like to thank Ashley N. Derby, ACNP, and Katie Gothard, BS, for their invaluable contribution to data collection. The authors would also like to thank all former aesthetic surgery fellows of Grotting Plastic Surgery, each of whom were instrumental in refining the elements of this technique.
Disclosures Dr Grotting is a founder and shareholder of CosmetAssure (Montgomery, AL), an author for Quality Medical Publishing (St. Louis, MO) and Elsevier (New York, NY), and a shareholder of Keller Medical (Stuart, FL) and Ideal Implant (Dallas, TX). The other authors have nothing to disclose.
Funding The authors received no financial support for the research, authorship, and publication of this article.
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