Reduction Mammaplasty procedure and post op management.pptx

This briefly summarise about reduction mammoplasty procedure and its post op management

1. Reduction mammoplasty Dr.Anteneh M (PRSR V) – AAU Moderator – Dr. Getaw (Consultant plastic and reconstructive surgeon)

2. Outline Introduction Anatomy Indications Patient selection Techniques and marking for Inverted T technique E.g of different dermal pedicles Complications

3. Introduction Over 50 variations and techniques: Based on skin pattern design and pedicle selection for nipple areolar complex transposition Skin patterns: Range from short scar to long scar techniques Nipple transposition techniques: From free graft to dermal pedicles to dermoparenchymal pedicles No consensus on single technique sufficient for all patients and breast types Individualized approach is used

4. Anatomy Reduction mammaplasty requires a specific understanding of breast anatomy with an emphasis on the parenchymal architecture, vasculature and innervation.

5. Blood supply Internal mammary, lateral thoracic artery/vein , intercostal & thoracoacromial vessels. Dominant blood supply : internal mammary perforators Other important supplies : intercostal , thoracoacromial vessels. Pedicles must capture one or more of this perforators for the nipple areolar complex.

6. Vascularity to nipple areolar complex : Primary supply : Subdermal plexus from internal mammary & lateral thoracic perforators. Contributors : Intercostal vessels, particularly the 4 th intercostal Wuringer’s septum : Contains 4 th intercostal artery & vein, crucial for maintaining blood supply directly to nipple areolar complex. Importance : Ensures vascularity in cases of peripheral subdermal plexus is compromised

7. Innervation of breast & nipple areolar complex : Intercostal nerves : from 2 nd – 6 th intercostal spaces. Preservation of sensation needs understanding of neural pathways within the breast. 3 rd – 5 th lateral and anterior intercostal nerves innervate the nipple areolar complex.

8. The course of anterior nerve is more superficial in the majority of cases, whereas the lateral intercostal traversed more deeply within the pectoral fascia in the majority of cadavers. The implication is that sensation is more likely preserved by minimizing the amount of medial dissection and by preserving the deep central mound along the 4th intercostal segment .

9. Indications Cosmetic Reduction Patients : Mild to moderate hypertrophy Minimal reduction (<300 g) Not symptomatic & focus on aesthetics. Functional Reduction Patients : Moderate to severe hypertrophy Symptomatic (back pain, intertrigo, postural changes) Primary interest in symptom relief Special Cases : Thin, petite women with relative hypertrophy may benefit from a reduction <300 g

10. Patient selection : History & physical examination : Common complaints - back pain, neck pain, postural changes, bra-strap indentations, and intertrigo; Assess for comorbidities like DM, HTN & cardiac disease. Evaluate if breast size affects daily activities ; inquire about effectiveness of prior weight loss efforts. Insurance considerations : Document functional impairment for insurance preauthorization. Mammogram recommendation : Advised for women >35 years old.

11. Examination : Assess volume, symmetry; measure sternal notch to nipple, inframammary fold, base width, and nipple to sternum distances. Risk Vs. Benefit discussion : Inform patients about potential outcomes and complications , Symptoms may improve, but it is not a guarantee Bleeding, infection, scarring, fat necrosis, altered sensation, inability to adequately nurse following childbirth , delayed healing; poor cosmetic result Partial or total nipple areolar necrosis Further surgery Incisional patterns and pedicle techniques are reviewed with each patient.

12. Surgical approach : Inverted-T for >300 g resections Short scar techniques for <300 g Select pedicle techniques based on nipple position adjustment .

13. The central mound or superomedial pedicle is considered when nipple elevation is <6 cm Medial pedicle is considered when nipple elevation is > 6 cm. Inferior pedicle is selected when the length of the proposed inferior pedicle is less than the medial pedicle Free nipple graft is considered when the pedicle length exceeds the perfusion capacity of the vascularity to the nipple areolar complex

14. Technique : Inverted-T pattern Has undergone several modifications Origins : Robert Wise's pattern mimicked brassiere manufacturing considering the conical breast shape. Classic inverted T pattern involves vertical and horizontal limbs with a keyhole apex for nipple areolar complex inset. Modified inverted-T pattern has been shown to have consistent and reproducible outcomes and is currently adopted.

15. Markings The sternal midline is delineated. The breast meridian is delineated bilaterally bisecting the midline of the breast Any pre-existing asymmetry of the nipple areolar complex will be corrected during the operation in order to center the nipple along the breast meridian and to ensure that the distance from the sternal midline to the nipple will be equal on both sides.

16. Markings The inframammary fold is delineated bilaterally The ideal nipple position is marked and based on the level of the inframammary fold. This may be done with calipers or freehand .

17. Markings The vertical limbs of the inverted-T pattern are delineated with a length that ranges from 8-9 cm. This will vary based on the volume of the breast . The angle of the apex is usually 60° and can be narrowed or widened based on the base width of the breast. For breasts with a wide base width , the angle can be increased to 70° and that will facilitate narrowing of the breast. For breasts with a normal to narrow base width, the angle is reduced to 50°.

18. Markings Although the keyhole pattern is described with the original description, the authors prefer not to delineate the keyhole at the time of the original markings but rather wait for completion of the reduction mammaplasty to accurately place the nipple areolar complex

19. Markings The horizontal component of the inverted-T pattern is then marked and extends from the inferior point of both vertical limbs to the lateral and medial limits of the inframammary fold. The horizontal incision should never cross the sternal midline and should be tailored laterally to eliminate any dog-ear and to follow the desired lateral mammary fold to optimize contouring and appearance

20. Benefits of inverted-T technique Accurate resections : Wide exposure allows precise glandular tissue removal. Versatility : can be applied to breast of every size and especially effective for breasts needing substantial (>300 g) resections. Cosmetic advantages : Horizontal scar is concealed in naturally ptotic breasts. Complication profile : Similar to short scar techniques. Postoperative appearance : Typically excellent , less dependent on remodeling and scar contracture compared to short scar methods.

21. Outdated techniques Strombeck : horizontal bipedicle McKissock : Vertical bipedicle

22. Complications Bleeding ; infection; Scar, asymmetry Hematoma ; seroma; delayed healing Nipple areolar necrosis; T-junction necrosis/delayed healing Inability to breast-feed Loss of nipple sensitivity Fat necrosis Contour abnormality Asymmetry Further surgery

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