This patient presents from Missouri, having had three operations for her breast enhancement. She has consistently had problems, including right breast double-bubble breast deformity with superior retropositioning of the implant and skin laxity of the lower pole. Also, there is severe bottoming out of the left breast where the implant is placed too low. She underwent a vertical mastopexy; however, the skin inframammary fold was never addressed and the skin laxity remains. She now presents for her first surgery with us in order to have this reconstructed.
In her preoperative photograph, it is evident that the upper pole of the right breast is quite full. There is also skin laxity on the right nipple and is significantly lower than the left side. On the left breast the implant is positioned quite low and there is increased skin laxity along the inframammary fold. The operation included both scar tissue removed, an open capsulectomy of the right breast, as well as an inferior open capsulotomy, releasing the implant bringing it down, as well as repositioning of the nipple areolar complex by doing a complete lift, that is, a formal mastopexy using the inverted-T or the Wise-pattern technique.
Specimen of the capsule removed is shown. The formal mastopexy was performed on the right and on the left a vertical T mastopexy with the specimens now showing skin removed (specimen #2) with 6 cm of skin removed from the inframammary fold reducing her bottoming out from 13 cm down to 7 cm. The implants were also replaced to regain symmetry with slightly different implants. High profile saline implants, 320 cc filled to 330 cc on the right, and 350 cc filled to 380 cc on the left, allowed volume symmetry.
Her postoperative Day 1 photographs are shown. With the bra open, note the upper pole fullness is even. The nipple positions are also the same level and that there is no longer bottoming out of the left breast. With the Linder Bra in place notice the cleavage is enhanced, there is great upper pole fullness with symmetry and the breasts are even. This is the case of a very difficult breast reconstruction where the patient actually presented with two problems, a double-bubble deformity (implant too high) and bottoming out (implant too low). By performing the correct surgery, i.e., a formal mastopexy rather than a vertical lift, it was quite easy to regain symmetry, narrow the breast with high profile saline implants and have upper pole fullness with symmetry as well.
The effects on the nipple from breast augmentation, breast revision, breast lift and breast reduction can be significant. They can include loss or gain of increased sensitivity to the nipple areolar complex. The nerve supply is the 4th lateral intercostal nerve that supplies the nipple areolar complex coming from the side of the chest around the muscle, the peck major, and underneath the nipple. If this is damaged, you could have obvious complete loss of the nipple sensitivity.
Sensitivity is associated with preservation of that nerve. This nerve can be stretched with neurapraxia or cut completely or blunt traumatically torn during lateral dissection of a breast augmentation procedure with either saline or silicone implants.
The loss of sensitivity ranges throughout the United States somewhere between 4 and 5 percent, by reports, for breast augmentation. The number greatly increases with breast lifts and breast reductions which can reach up to 10 to 14 percent. Hypersensitivity can also occur to the nipple areolar complex with new neuronal regrowth of nerves underneath the periareolar incision which could lead to hypersensitivity.
In general, after eight weeks usually the sensitivity returns to a normal state as baseline preoperative. However, it can take 12 to 18 months for complete sensitivity to return or at least partial. Breastfeeding can also be lost with all three procedures and again similarly the numbers increase as you go from breast augmentation to breast reduction.
Any patients who will undergo a breast implant, breast lift or breast reduction, must be cognizant of the fact that they may certainly lose sensitivity and/or the ability to breast feed or lactate. Certainly, the technical skill of the surgeon being Board Certified with the American Board of Plastic Surgery should reduce the incidence of these deleterious effects.
The patient below is a 32-year-old Asian female that had significant nipple hypertrophy. This type of deformity is mostly encountered in the Asian population and, occasionally, in Caucasians. There is no “normal” female nipple, but it is usually roughly 1 cm in diameter with an almost equal amount of anterior projection. Along with her desire to reduce the size of her nipples, she also requested a breast augmentation
. After listening to her expectations, we scheduled her surgery.
For the nipple reduction, I carefully went through a pedicle base, and for the augmentation, I used 240 cc SRF silicone implants. Her results two weeks postoperatively now show excellent symmetry to the nipple with some slight scarring healing around the periareolar incisions.
Patients often present for nipple reduction. This is a procedure where the patients present with nipple hypertrophy. Symptoms of nipple hypertrophy can include pain, excoriation, rash, embarrassment, psychological and self-esteem issues. It can also be difficult to wear clothing due to enlargement of the nipple with exposure. Excoriation, rashes and irritation of enlarged nipples also have been seen in our patients.
The operation is a procedure usually performed in combination with breast augmentation or breast lifting in which I perform a superior pedicle flap. Resection of the inferior half of the nipple is performed down to the base with a 15-blade. Subsequently, the superior pedicle is inferiorly rotated, fits down with simple 5-0 Prolene sutures. The 3 and 9 o’clock position of redundant skin is then trimmed carefully and those edges are sutured as well. Stitches usually remain in for approximately 14 days. Scarring is minimal to none in that the scars feel extraordinarily well. I have never experienced a hypertrophic keloid or widespread scar of the superior pedicle nipple reduction. The key to nipple reduction surgery is proportionality of the nipple to the areolar size.
Notice in the preoperative photographs this patient has an extremely large nipple in proportion to the areola. It is approximately 65% in diameter to that of the areola. Her postoperative view shows this has been reduced to approximately 45%. The vertical height and the base have also been reduced, allowing for more proportionality with the actual implant as well as the areola.
The patient below presents with a 125-pound weight loss after a laparoscopic banding procedure leaving her with severe asymmetry, grade 3 ptosis (right breast significantly larger than the left with asymmetry), a significant abdominal pannus, skin laxity, rectus diastasis and lipodystrophy of the hips. The patient is now two months postoperative with 500 cc high profile Natrelle saline implants placed in the dual plane technique, formal mastopexy or Wise-pattern skin excision was performed, creating a tightening procedure of bilateral breast, as well as a full abdominoplasty with plication tightening of the rectus sheath and liposculpturing of the muffin-top area was accomplished. Preoperative photos show severe asymmetry requiring slightly different volume implant placement (right smaller than left in terms of volume of implant size) and bilateral complete mastopexies reducing the large areola to 4.2 cm. Notice the right areola preoperatively was approximately 9 cm wide. She also has skin laxity in the lower abdomen which requires a full abdominoplasty with plication of the midline muscles of the rectus sheath. Her oblique views show excellent contouring with nice fullness to the upper pole of her breast associated with the high profile saline implant. She has good nipple positioning without skin laxity along the inframammary fold. The lower abdomen shows nice concavity with tightening of the rectus muscles, excellent definition of the midline and smoothing out of the hip region. Patients who undergo gastric bypass surgery from Rouen-Y procedures, gastroplasties or laparoscopic banding, once they have lost a significant amount of weight, reaching the baseline, will do well with reconstructive surgery of both the breast and abdominal areas, as this patient is an excellent example.
The above patient presents with significant nipple hypertrophy, left breast greater than right as well as hypoplastic breasts. She is a good candidate for augmentation mammoplasty procedure using high profile smooth round saline implants in the dual plane technique through a periareolar approach and a left nipple reduction reducing the left nipple through a superior pedicle flap. The inferior portion of the nipple was resected straight down to the base. The nipple was then inferiorly repositioned, sutured and the medial and lateral positions of the nipple were then resected and sutured down. Her results now show a five-week postoperative with excellent symmetry to the nipple areolar complexes with still some scarring healing around the periareolar incisions with good symmetry to the upper poles, cleavage and the inframammary folds are even. Nipple reductions should be done carefully through a pedicle base. I prefer the superior pedicle in order to allow viability of the blood supply through the nipple and allow for reduction in size and shape.
GIGANTOMASTIA SURGERY: BREAST AMPUTATION
WITH FREE NIPPLE GRAFTING
The patient below is a 48-year-old female presenting with massive gigantomastic breasts/breast hypertrophy, 40KK breasts, with symptoms of severe back pain, neck strain, grooving around the shoulder blades and coracoid aspects of the shoulders, including ulnar neuropathy, rashes and ulcerations of the breasts due to poor circulation associated with the massive skin laxity and grade 3 ptosis. This patient is a perfect candidate for bilateral breast reduction using the breast amputation technique with a free nipple graft. The pedicle will probably be approximately 30 cm long, if not longer, and therefore will require most likely a free nipple graft in the operating room in order to prevent avascular necrosis of the nipple areolar complex due to the length of the pedicle and inadequate blood supply through osmotic diffusion.
The frontal and oblique views of this patient will be shown. This patient is an extraordinary case due to the massive size of her breasts as well as the severe degree of skin laxity and ptosis. These surgeries require skillful Board Certified Plastic Surgeons who specialize in breast reduction to reduce the risk of fat necrosis, bleeding, infection and nipple areolar necrosis.
Patients are seen who have nipple hypertrophy and will do well with reduction in the size of the nipple to make it more symmetric with the areolar complex. These patients often are from Asian, Korean or Chinese descent. Often, the nipple will be excoriated with the skin. They can develop dermatitis due to rubbing and will do well with functional reduction in size. Dr. Linder’s perform technique includes the superior pedicle and excision of the inferior portion or lower portion of the nipple and the nipple is then brought down and sutured down and the sides are then trimmed. This makes for a significantly smaller nipple, both along the AP projection as well as the width. Nipple reduction surgery patients are very satisfied both for cosmetic as well as the functional reasons, with reduction in pain, irritation and the dermatitis which occurs due to the raw surface of the tip of the nipple region.
The nipple specimen is always sent to pathology to make sure that there is no evidence of cancer or Paget’s disease.
Reconstruction of severe congenital breast asymmetry should only be performed by Board Certified Plastic and Reconstructive Surgeon. This is a very difficult operation in which the breasts must be reduced while maintaining and preserving sensitivity as well as blood supply to the inferior pedicle, maintaining the nipple areolar complex. This patient specifically presents with left breast asymmetry, two cup sizes larger than the right. She will undergo bilateral reduction mammoplasty on the left breast only using the inferior pedicle Wise-pattern technique. Approximately 180 grams of tissue was removed. Skin was removed circumferentially around the nipple areolar complex vertically on the inferior pedicle and medial and lateral dermoglandular flap dissection was accomplished. This patient is now six months postoperative. We have reduced about one and a half cup sizes on the left, equaling symmetry to the right breast. We have also raised the nipple areolar complex on the left. It will continue to slightly descend over the next six months.
The next photo shows the patient in her brassiere, showing excellent symmetry with good upper pole fullness on the left, equal to the right side. Congenital breast asymmetry on a simple unilateral reduction mammoplasty such as this can lead to excellent results. It is extremely important not to over-resect tissue on the affected breast which could lead to severe deformity requiring implantation.