Surgery for mild to moderate breast hypertrophy

In case of minor and moderate degrees of hypertrophy of the mammary glands, the choice of surgical technique for their reduction must be made taking into account not only the volume of the glands, but also the degree of their ptosis.

When the initial distance from the areola to the submammary fold does not exceed 12 cm, a good result is achieved by using the vertical reduction mammoplasty technique. This technique allows you to form only a vertical postoperative scar and a scar around the areola, as well as achieve a stable result.

Vertical reduction mammoplasty

The principle of the operation is the central resection of the breast tissue (skin, adipose and glandular tissue), transposition of the nipple-areolar complex on the upper dermal pedicle and completion of the operation by applying a vertical suture.

Preoperative marking is performed with the patient in a standing position. The midline and submammary fold are marked, and the new position of the nipple is determined, which is located slightly above the projection of the submammary fold level (on average, at a distance of 20 cm from the jugular notch along the line connecting the notch and the nipple in the new position.

Then the vertical axis of the mammary gland is marked, which is usually located at a distance of 10-12 cm from the midline. This line is used as a guide when determining the lateral borders of the resected skin.

After this, the gland is moved medially and a line is drawn on the moved tissues, which should coincide with the vertical axis. This marks the outer border of the resection. Then the gland is moved laterally and the inner border of the resection is determined in the same way. The lines of the outer and inner borders are smoothly connected to each other at a point located 4-5 cm above the inframammary fold, which will correspond to the lower border of the resection.

The next step is to draw a curved line that marks the edge of the skin wound around the new areola. The top point of this line is 2 cm above the new location of the nipple. The length of the curvature should not exceed 16 cm. This line connects two vertical lines.

Within the designated boundaries of the markings there is a field of de-epidermization, the lower edge of which is located 2-3 cm below the level of the nipple-areolar complex.

Technique of the operation. The patient is anesthetized and placed in a semi-sitting position by bending the operating table. The skin around the areola within the upper flap is superficially infiltrated with a 0.5% lidocaine solution with the addition of adrenaline. This facilitates subsequent de-epidermization. The resected part of the mammary gland is infiltrated to its full depth.

The operation begins with de-epidermization of the marked area of skin. Then, along the outer and inner borders of the marking, an incision is made in the skin and subcutaneous fat to a depth of 0.5 cm, and the skin is peeled off with a thin (0.5 cm) layer of fat from the gland.

The detachment boundaries are: downwards to the submammary fold, inwards and outwards - to the lateral boundaries of the base of the mammary gland and upwards - to the level of the lower edge of the new location of the areola. It is important to note that the superficial detachment of the skin-fat flap allows the skin to contract after surgery. A thicker layer of tissue prevents this process, and after surgery, sagging of the skin in the lower part of the gland may be observed.

Next, the gland is detached from the chest wall from the bottom up from the level of the submammary fold to the upper border of the mammary gland. The width of the detachment zone should not exceed 8 cm (in order to preserve the lateral sources of nutrition of the gland).

The next stage is resection of glandular tissue. In case of moderate hypertrophy, resection of glandular tissue is usually performed along the marked boundaries of excess skin removal. In case of more pronounced hypertrophy, the resection zone of glandular tissue is expanded towards the nipple and areola, while maintaining the thickness of the de-epidermized flap at least 2-3 cm.

After removal of excess tissue, the upper part of the gland is additionally fixed to the periosteum of the 2nd or 3rd rib and to the pectoral fascia with a suture made of non-absorbable material. Then the edges of the remaining glandular tissue are brought together and sutured together.

After fixing the areola in its new position to the edges of the skin wound, the vertical part of the wound is closed. To do this, temporary sutures are placed on the edges of the skin (from top to bottom) and it is assessed whether additional tissue resection is required. If necessary, stepping back from the first line of sutures, additional sutures are placed on the skin, as a result of which the shape of the gland improves. If the surgeon is satisfied with this result, he marks the boundaries of the new suture line with methylene blue and draws 3-4 horizontal lines across them, numbering them on both sides. Then the sutures are dissolved and the final resection of the edges of the skin wound is done in accordance with the final marking. Next, two-layer final sutures are placed on the skin, matching the horizontal lines. A subcutaneous immersible suture made of non-absorbable material ensures tight contact of the edges. The operation is completed by placing an intradermal continuous removable suture and matching sutures on the skin (4/0 prolene). In this case, the suture must be placed on the lower pole of the gland. Note that after the breast tissue is moved upward, the length of the skin wound begins to significantly exceed the length of the lower pole of the gland. Therefore, an important element of the final stage of the intervention is the corrugation of the skin wound after the application of an intradermal removable suture. As a result, its length is reduced to 5-6 cm. The wound is drained with tubes.

The peculiarity of this operation is that at the end of the intervention the upper part of the gland has a convex shape, and the lower part is flat. However, in the postoperative period the skin gradually straightens out. The final shape of the gland is formed in 2-3 months.

The skin matching sutures are removed 5 days after the operation. The continuous intradermal suture is removed after 2 weeks. The bra is not worn for 3 months until the gland takes its final shape.

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