Breast reduction & Mastopexy Flashcards by Rayisa Hontscharuk

What is your differential for unilateral breast hypertrophy in teenager?

Fibroadenoma
Cystosarcoma phylloides
Unilateral virginal breast hypertrophy
Trauma
Hamartoma

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list different etiologies for breast hypertrophy

idiopathic
developmental
- juvenile breast hypertrophy
- obese
Endocrine
- endocrinopathy / precocious puberty
- pregnancy / lactation
- post-menopausal
- drug induced - penicillamine, cyclosporine etc

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list Penn’s ideal breast measurements

Sternal notch and NACs form equilateral triangle
Triangle limbs= 21cm
Mid-clavicular line to nipple =21cm
Nipple to IMF = 6-7 cm
Areolar diameter = 35-45 mm
Nipple diameter = 5-8mm
Nipple projection = 4-6mm
Ideal shape = conical

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describe history for breast hyperplasia:

Kerrigan’s 7 symptoms associated with medical indication and happy patients: upper back pain, neck pain, shoulder pain, arm pain, shoulder grooving, rash/intertrigo, change to NAC sensitivity
Other symptoms: headaches, difficulty with clothes, posture changes, symptom relief with relief of traction, psychosocial
Other features on history to ellicit:
- establish: goals and expectations, current and desired size
- breast feeding/child bearing/future reproductive plans
- breast cancer rf.’s: age at menarche, children, breast feeding, previous breast biopsies, previous screening / diagnostic breast investigations or biopsies, personal or family history
- general medical health: smoking, comorbidities, weight loss/stability

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describe physical exam for consult for breast hypertrophy / breast reduction

Specific

examine when standing and follow footprint/conus/envelope/symmetry
inspection:
gross asymmetry in size, shape, amount of ptosis, level of NAC, intertrigo
ptosis, quality of skin (straie, scars), size of NAC & nipple, quadrants of fullness/hollow, decolletage/cleavage, larger/more ptotic side
palpation: pinch test, breast cancer exam incl LN
measurements
Penn’s ideal measurements: above
also measure: distance from IMF to NAC (for inferior pedicle) or anticipated pedicle base to NAC (for other)
- < 10cm - ischemia/necrosis extremely unlikely
- 10 - 20cm - ischemia / necrosis with additional RF (ex: smoking)
- > 20cm - may want to consider alternate pedicle or free nipple graft

General

height/weight/bmi/habitus
posture; kyphosis; scoliosis
shoulder groove
Photographic documentation: 5 views

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what are the goals of surgery for reduction mammoplasty?

improve patient symptoms
design a reliable dermoglandular pedicle to preserve blood supply and innervation to nac
reduce breast volume by parenchymal excision while maintaining vascularized, sensate nac
reposition nac while maintaining vascularized, sensate nac
reduce the skin envelope around the reduced breast size
aesthetic, symmetric, durable result
preserve potential for lactation if possible
minimize scar

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describe informed consent for reduction mammoplasty

Discussion should include: general risks of any surgical procedure including risks of anesthesia + specific to procedure
Specific to BBR:
- Location of surgical scars: permanent + possibility of thickening/ widening
- Bleeding, hematoma, seroma
- Infection
- Wound healing problems
- NAC necrosis (partial/ total)
- Skin flap necrosis
- Fat necrosis
- Altered nipple sensation: temporary vs. permanent
- Difficulty breastfeeding
- Breast asymmetry / NAC malposition/ pseudoptosis
- Recurrence of breast hypertrophy, post-menopausal
- Possible need for increased investigations in future secondary to scarring (biopsy, imaging, etc)
- Consideration of free NAC graft for certain patients

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how do you classify surgical options for breast reduction?

skin
- peri-areolar, vertical, inferior T (wise)
pedicle
- inferior (Robins)
- superior (Wiener)
- medial (Hall-finlay)
- superomedial
- less common: lateral (skoog), central mound (Hester), bipedicle: vertical (mcKissock), horizontal (strombeck)

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describe NAC pedicle and blood supply

Inferior – perforator is 4^TH IMA deep perforator (and central mound pedicle)
Bipedicle: Vertical (McKissock); Horizontal (Strombeck); dermoglandular pedicle from 2nd & 4th IMA
Superior – 2^nd IMA perforator, superficial, enters NAC 1cm deep nearly at meridian
Medial – 3^rd IMA superficial perforator
Superomedial – true superomedial pedicle contains both 2^nd and 3^rd IMA superficial perforators
Lateral – superficial lateral mammary branch of lateral thoracic artery

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how do you determine new nipple and areola position?

Top of neo-nipple:
- IMF translated and marked on anterior surface of breast
- 20-21 cm (small-moderate size breasts)/22-26 cm (larger breasts)
- Midhumeral height
- 10cm inferior to superior border of footprint (Hall-Findlay)
Upper border of areola should be ~2cm above position of new nipple for WISE
Superior margin of neo-areola follows the above markings for neo-nipple (ie don’t move it another 2cm up)

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describe how you will make skin markings for wise-pattern skin for reduction mammoplasty

Always mark conservatively à can take skin and narrow pedicle later
Patient standing/sitting
Measure: SN-N, N-IMF
Midsternal line, breast meridian, IMF
Top of neo-nipple:
- IMF translated and marked on anterior surface of breast
- 20-21 cm (small-moderate size breasts)/22-26 cm (larger breasts)
- Midhumeral height
- 10cm inferior to superior border of footprint (Hall-Findlay)
Upper border of areola should be ~2cm above position of new nipple (point 1)
+/- Template used to make markings; 14cm circumference = 4.5 cm areola
- 7cm across and 4.5cm height, with 4cm gap at bottom of mosque (to free-hand areola marking)
Vertical limbs: lines drawn down from neo-NAC marking ~ 5-6cm in length (line 2)
- range=5-8 cm in length, depending on current / desired size of breast
- width btwn limbs: 9 – 11 – 13 (for small, mod, large anticipated breast / reduction)
- a + b > c; C line laterally to anterior axillary line and medially to ptotic corner
- If inferior pedicle, width=>8-10 cm (approx 1:2 width:length – ie measure N-IMF)

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describe skin markings and pedicle selection/marking for circumvertical reduction mammoplasty

Patient standing/sitting
IMF, Midline, breast meridian to intersect IMF
Neo-nipple position
- previous 4 markers (esp anterior transposition of IMF) = Superior margin of neo-_areola_ (Pt A) vertical reduction gives more projection
Top of mosque at desired superior margin for neo-NAC
- When pt C & D converge, will form a circle
- Mosque ~4cm in height, 7cm in width – goal areola 4-5 cm diameter
- Lista - blocking triangles from C to D à prevents teardrop deformity of NAC
Breast moved laterally & superiorly, vertical line drawn down from mosque
Breast moved medially & superiorly, vertical line drawn down from mosque
2 lines should converge to a point (Point B) ~2-4cm above IMF
- Larger reduction: Point B higher above IMF
- Inferior vertical incision can be rounded (Lejour/Hall-Findlay) or point of ellipse (Lista)
Technical points
- Superior or medial pedicle (depends on NAC elevation/rotation)
  - NAC below line D-C = medial pedicle (or lateral)
  - Any part of NAC above line D-C = superior pedicle
  - This limits pedicle length, preventing NAC compromise
  - Pedicle base: 6-8 cm
  - Pedicle creation: 1 cm of tissue around areola

Lateral and medial pillar preservation and approximation (pillar stitches) to give conical shape. Most inferior pillar stitch >4cm above inferior point of incision to prevent dog ear

+/- Vertical incision gathering (to shorten)
- “Box” stitches starting at distal end (Lista)
- Bunched subcuticular suture
Simultaneous SAL possible – infiltration prior to incisions with tumescent solution
May incorporate a short transverse scar to eliminate distal vertical dog-ear

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list indications and disadvantages of free nipple graft

Indications
- SNN > 40cm
- Resection >2500g
- NAC reposition >15cm (ie measure mid-clav to N, measure mid-clav to desired neo-NAC, get the difference)
- NAC-IMF > 20cm (long inferior pedicle)
- Significant systemic diseases that may impair blood flow
- Patients with previous operations or chest wall radiation that may impair blood flow
- Patients requiring short anesthesia times
Disadvantages
- Possible depigmentation in dark areola
- Loss of nipple sensation
- Loss of lactation potential
- Poor projection

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list complications to reduction mammoplasty

EARLY

LATE

Specific:
- Hematoma/bleeding
- Seroma
- NAC vascular compromise (4-7%)
- Skin flap necrosis
- Infection (abscess, cellulites)
- Wound dehiscence (T-junction) or areola
- Fat necrosis
- Altered NAC sensation (10-25%)
- Galactorrhea (first 2 weeks)
- Mondor’s disease
General
- DVT/PE
Over- or under-correction
Asymmetry of breast or NAC
Pseudoptosis/bottomimg out
Inability to lactate
Unsatisfactory scarring / HTS / KS
Prolonged edema
Dog ears
Indentations (too much tension on pillar closure in vertical scar)

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discuss treatment of complications

High-riding nipples**VERY difficult to treat: a) horizontal wedge excision along IMF, b) direct repositioning NAC, c) implant placement to project nipple better, free nipple graft
Nipple loss: nipple sharing, local flaps, tattooing, skin grafts
Asymmetry: liposuction, re-reduction
Breast loss (partial or total): treat as breast reconstruction
Fat necrosis: FNA to r/o CA, observation, excisional biopsy
Dog ears: revision, liposuction, wait 1 yr
Postop hematoma: NAC in danger 2^o direct pedicle pressure, vasoconstriction due to inflammatory mediators, direct toxic effects of blood byproducts
Scar revisions: wait 1 year
NAC malposition/ pseudoptosis: move nipple or breast, wait 1 yr (Ok to do inf wedge resection or BBA thru IMF for pseudoptosis thru prior inf pedicle BBR if >1yr)
BBR and NAC sensation: according to many studies <400 g reductions can expect almost 100% sensation – if lost returns in 2 to 12 months on average
BBR and lactation:~60-70% able to breastfeed postop

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briefly discuss approach to revision BBR

·Risks of all complications increased in revision reductions (wound healing, fat necrosis, nipple necrosis, infection).

oABSOLUTELY NOT in a smoker.Patient MUST accept these risks and ↑ potential for nipple graft

·find out initial technique, follow the same pedicle

·If 1⁰ pedicle unknown or in doubt à use free nipple graft vs. inferior pole wedge (if NAC position good) or vertical pattern with superior pedicle (Lista 2011)

·BROWN: if Wise pattern incision, stick to the same and use an inferior pedicle (this is what was most likely used – just keep broader base), but don’t cut the keyhole until the end

·Okay to do BBA thru IMF or PA incisions post BBR or revisions requiring transection of prior inf pedicle as long as not also repositioning/mobilizing NAC at same time

what to do if permanent path report shows occult invasive malignancy in specimen

Incidental finding of breast cancer in BBR specimen: Rare 0.16-1%, Should be followed by: thorough workup, oncologic consultation and Rx (likely imaging, complete mastectomy)

what do you do if you come across a suspicious lesion in breast DURING breast reduction?

Intraoperative suspicious mass during BBR
- Intraoperative frozen sections
- Intraoperative Gen Sx consultation (*consider only doing if frozen section comes back malignant)
- If mass
  - Benign àclip, excise + no further treatment required
  - Malignant à entire mass excised, biopsy site marked (staples or clips), breast closed/ case terminated (to obtain closure – will likely need to complete resection but do as minimal as possible to close breast; if contralateral breast has not been cut yet – then DO NOT perform; if it has been cut e.g. simultaneous resection, then complete & close); postop formal workup (staging, oncologic consultation)
  - If on pedicle: don’t excise mass, mark with clips, close breast (if have consent and haven’t cut out mosque yet e.g. in Mahoney’s technique, then can covert to free nipple graft and excise mass)

describe considerations for BBR in adolescent pt

Hormone induced occurrence
Virginal hypertrophy
Difficulty breast feeding in the future
Emotional & physiological maturity
Scars
Interference with mammography
Management: Counseling & Breast feeding_,_ Discussion of scars and possible recurrence in great length; aim to wait until breast maturity if possible (done growing x ~ 12 mos)

discuss management of intra-operative dusky nipples/NAC

Initial steps: check systemic issues first (hypo/hypertension, hypothermia, u/o, O2 sat), release sutures, check for kinking of pedicle, hematoma warm saline soaks, give time
If nipple remains venous congested
- McKissock or have not yet cut out mosque – can salvage with free nipple graft (need consent)
- If pedicle cut already – need to decide if NAC has chance of surviving or not
- no change: take NAC off pedicle as graft & bank in groin (make incision parallel to inguinal fold, elevate skin flaps, & bury NAC, close skin over top), also need to debride pedicle back to bleeding tissue. Replace NAC when breast fully healed (months)
- ? salvageable: admit pt, pack open breast or loosely tack, put on Abx, warm saline and/or hep soaks, leeching, maintain hydration/BP/Temp, decide in 2-3 days if survived (yes – return to OR to close BBR; if no – must discard NAC & plan for delayed NAC recon & also debride pedicle)
**NB – arterial insufficiency to NAC is rare. Usually venous

What is the purpose of mastopexy

Elevate the NAC & breast parenchyma
Reduce the skin envelope

Describe the pathophysiology and risk factors for breast ptosis

Breast ptosis results from a combination of factors such as:
- skin: laxity, reduced recoil, relative excess
- parenchyma: involution, maldistribution, atrophy, fibrolipomatous change
- fibrous & ligamentous breast tissue (investing breast fascia, cooper’s ligaments): laxity, reduced recoil
RFs/etiologic factors:
- age
- gravity
- pregnancy, lactation
- menopause
- weight fluctuations
- genetic predisposition
- genetic or congenital anomalies

How do you classify breast ptosis?

Regnault classification
Grade 1: Nipple at or within 1cm of IMF
Grade 2: Nipple below IMF, not at most inferiorly projection part of breast (~ 1-3cm below IMF)
Grade 3 ptosis: Nipple below the IMF, sitting on the most inferiorly projecting part of breast (> 3cm below IMF)
Pseudoptosis: the Nipple is above the IMF but the majority of breast parenchyma is below the IMF

What factors do you consider when choosing an operation for breast ptosis?

Procedures to address the amount of NAC ptosis (grade 1-3)
Procedures to address the amount of excess skin (mild/mod/severe)
Procedures to address the quantity and distribution of parenchymal (sufficient, insufficent, excess)
Scars the patient is willing to accept
Generally, amount of NAC ptosis and amount of skin excess are similar, and the chosen operation will address both components to a similar extent

What are teh goals of mastopexy?

1. Restore firm, youthful, durable breast appearance 2. Elevate the NAC 3. Tighten the skin envelope 4. Reshape the parenchyma 5. Maintain vascularity and sensation to NAC 6. Minimize scar burden

Describe how you will choose an operation for primary mastopexy

1. To determine the incisions: 1. Assess amount of NAC ptosis and skin excess 1. Mild ptosis / excess: peri-areolar/concentric/eccentric 1. Consider implant only if insufficient parenchyma 2. Moderate ptosis / excess: Circumvertical, short vertical scar 1. Consider inverted T if relative SKIN excess vs. ptosis 3. Severe ptosis / excess: Inverted T 2. To determine the approach to parenchyma 1. Parenchyma sufficient 1. skin redraping over parenchyma 2. parenchymal redistribution & resuspension 2. Parenchyma insufficient: 1. Augment alone 2. Mastopexy w/ augment 3. Parenchyma excess 1. Choose reduction mammoplasty instead of mastopexy

List the advantages and disadvantages of periareolar incisions for mastopexy (or augment)

* Advantages: * scar hidden in juction between areola and skin * neurovascular supply to NAC preserved * Disadvantages * limited skin excision * minimal cephalic transposition of NAC * scar widening * flat/boxy breast mound

list advantages and disadvantages of vertical scar mastopexy (or BBR)

* advantages * balance between skin excision and scar burden * greater cephalic transposition of NAC (vs. peri-areolar) * can add parechymal modifications * can lift breast parenchyma nd narrow breast base * neurovascular status to NAC remains well perserved * disadvantages * larger/longer scar (vs. peri-areolar) * bunching of scar * dog ear * flat inferior pole

list advantages / disadvantages of inverted T scar for mastopexy

* advantages * greatest cephalic transposition of NAC * greatest reduction in excessive skin envelope * can use any approach to NAC pedicle, parenchymal redistribution * shorten N-IMF distance * predictable * disadvantages * largest scar burden * typically not done w/ augment * greatest risk to NV status of NAC

describe indications and contraindications to primary mastopexy after explantation of implant

* regnault II, III or pseudoptosis * NAC elevation \< 4cm * Parenchymal thickness \> 4cm * large areola contraindications * active smoker * preclusive pre-morbid disease * consider delayed mastopexy (after explant) if: \> 4cm NAC elevation, \< 4cm parenchymal thickness, recently quick smokiung

What are the advtanges and disadvantages of each pedicle type (dermal/dermoglandular and parenchymal)

Superior (Weiner - 2ndIMA perforator) * upper pole full ness, projection of nipple * But risk NAC congestion, paresthesia, difficult to move move up if ditatne \>10cm Medial (lejour, hall-finlay - 3rd IMA perforator) * upper pole fullness, can lateralize NAC * higher revion rate of vertical scar Inferior * easy to perform, lactation, NAC sensation preserved * But upper pole flat, pseudoptosis, long scar Lateral (skoog) * can medialize NAC * But poor lactattion, sensation, perfusion Central (hester) * maintained NAC sensation, lactation * But diffcult to move NAC superior? Bipedicled vertical (mckissok) * good projection w pedicle folding, bail out if NAC compromised to move as free graft * But poor lactation and NAC sensation, lots of pedicle, pseudoptosis Bipedicled Horizontal (strombeck) * But difficult inset, NAC retraction, boxy breast

What are the advantages and disadvantages of different skin incision patterns for BBR

WISE PATTERN * Works for any ptosis/reduction volume * works with any pedicle, reliable * But pseudoptosis, wound dehiscence, scar CIRCUMVERTICAL * no t junxtion dehisce, better coning, no pseudoptosis, no NAC stretch, shorter OR * less predictable more secondary revisions PERIAREOLAR * limited scar,preserved lactation * but wide areola, less projection, FLAT BOXY BREAST, need for permanent suture PERIAREOLAR PLUS SHORT VERTICAL SCAR - SPAIR * limited scar, * But same prob as perioareolar

What are indications and complications for SAL/UAL in context of BBR

* Lateral fullness * small reduction with minimal skin excess or ptosis * Fatty breast with good NAC position adn upper pole fullness * Correct asymmetry post reduction * gynecomastia Complications * unpredictable NAC shift, corerct ptosis * dififcult in glandular fibrotic breasts * no accurate histology