Marisa Marques

Breast reduction

(Usually two days of hospitalization)

The main goals of reduction mammoplasty are weight and volume reduction of the breast, although, aesthetic enhancement is often equally important.
Women seek to reduce the size of their breasts for reasons both physical and psychological. Heavy, pendulous breasts cause neck and back pain as well as grooves from the pressure of brassiere straps. The breasts themselves may be chronically painful, and the skin in the inframammary region is subject to maceration and dermatoses. From a psychological point of view, excessively large breasts can be a troublesome focus of embarrassment for the teenager as well as the woman in her senior years. Unilateral hypertrophy with asymmetry heightens embarrassment.
Postoperative care
The operation is mostly done in general anesthesia after which 2 days of hospital care is necessary. For 4 weeks the use of a surgical bra is advised. Patients are encouraged to gradually increase their activities.
Return to desk work may only take 1 to 2 weeks, whereas return to heavy physical activity may take several weeks. The pucker (dog-ear at the inferior end of the vertical incision) may take several weeks to months to settle. A seroma may occur that makes the pucker look more ominous, but seromas will settle relatively quickly without intervention.
Patients should be warned about the time it takes for resolution of the shape, any asymmetries, or persistent puckers. They should know that revisions may be necessary in a limited number of patients, but that a full year should pass before considering any corrective surgery.
After a classical surgery the scars can be found around the nipple, vertically below and in the crease – a T shape. In the case of a smaller breast reduction the operation is possible without the incision in the crease below the breasts.
Acute complications
Hematoma: A significant hematoma may require reoperation.
Nipple-areolar necrosis: Rarely, complete loss of the nipple and areola will occur. Each patient will need to be evaluated over time as to whether the necrotic tissue should be allowed to heal by secondary intention, in-office debridement, or intraoperative debridement. Some form of nipple and areolar reconstruction is then considered.
Infection: Infection rates should be no higher with breast-reduction surgery than other clean operations. A post operative antibiotic is administered to prevent this complication.
Wound healing: All types of breast reduction have problems with wound healing. Both of these can be prevented to some degree by avoiding undue tension on the incision lines. Avoiding tension can be harder with the inverted-T because the procedure relies more on the skin to hold the shape. Antibiotics may be helpful in reducing wound-healing problems. Extensive flap necrosis is rare. Debridement may be necessary. Skin grafting may close the wounds earlier, but the cosmetic result is often better if the open areas are allowed to heal secondarily.
Seromas: Seromas can occur with or without the use of drains. Even leaving the drains in for several days does not seem to prevent the development of seromas. Aspiration may be indicated, but the seromas will tend to recur. They can be left to resolve on their own. Although surgeons may be concerned that a pseudobursa may develop, this does not seem to be a problem.
Chronic complications
Underresection: At the end of the procedure, the breasts actually look smaller than they are. The extra projection can be misleading.
Asymmetry: Correction of asymmetry should follow similar guidelines to re-reduction. The problem may be solved by liposuction-only or it may require parenchymal repositioning, scar release, or excision.
Dog-ears: The excess skin can tuck in the edges of the incision. It is advisable to wait a full year before performing any revisions. At first glance, the pucker that remains may appear to be a problem of excess skin. But usually the real problem is excess subcutaneous tissue between the original and the new inframammary fold. Very little skin may need excision, and often the skin can be excised by carrying the scar down a bit further vertically, but not below the fold. Many of these revisions can be performed under local anesthesia. Each surgeon will have a different threshold for revision, but a rate of approximately 5% is not unexpected.
Fat necrosis: When this complication occurs, the patient notes a palpable hardness of the breast. Small areas of fat necrosis can be managed conservatively, especially if there is no skin necrosis. If skin and fat necrosis is extensive and associated with infection, surgical debridement and topical and intravenous antibiotics are required.
Nipple retractions: This is a rare complication of reduction mammaplasty after nipple transposition techniques. Minimal nipple retraction almost invariable resolves in several days. If nipple retraction persists postoperatively, secondary correction may be necessary after 3 to 6 months.
Nipple malposition: the “high-riding” nipple is the most common postoperative complication related to nipple malposition.
Scars: Scars are a distinct drawback of reduction mammaplasty and are the major drawback to mastopexy. In general, scar hypertrophy is more common after reduction mammaplasty than after mastopexy.
Loss of sensation: Larger breasrs, scarred breasts and breasts of multiparous women were associated with decreased sensation overall. Decreased sensation in nipples is a complication of reduction mammaplasty and mastopexy, but it usually returns to normal from 2 months to an year.
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