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Surgery for severe breast hypertrophy

Alexey Kryvenko, Medical Reviewer, Editor
Last reviewed: 04.07.2025

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In cases of severe hypertrophy of the mammary glands, only 500 to 1200 g of tissue is resected. In this case, good results are achieved by using the surgical technique with the formation of a lower tissue pedicle. Its shape resembles a pyramid, and therefore R. Goldwyn called this method of reduction mammoplasty the pyramidal technique. The advantages of this operation include ensuring reliable blood supply to the nipple-areolar complex and maintaining its sensitivity. A significant amount of tissue can be removed, and the areola can be moved to a new position at a distance of up to 20 cm.

The marking is done with the patient in a vertical position. The new position of the nipple-areolar complex is determined by a line running from the middle of the collarbone through the nipple. It is located at the level of the inframammary fold slightly below the normal position of the nipple and areola, since the skin of the gland contracts after the operation and the areola rises to its natural position.

Using a special template, which is a wire bent in the form of a keyhole, the new location of the areola and the vertical borders of the medial and lateral skin-fat flaps extending downwards from it are marked. The diameter of the areola is 4.5-5 cm. The vertical borders of the flaps are located at a slight angle so that the length of the horizontal edge of the lateral and medial flaps is the same. At the same time, the deviation of the vertical borders of the flaps should not be significant in order to avoid excessive tension on the edges. The length of the vertical edge of the flap should not exceed 5 cm.

To achieve the maximum aesthetic result of the operation and prevent disturbance of peripheral blood circulation in skin flaps, it is advisable to use the following technical methods:

a skin protrusion can be made in the center of the lower edge of the wound, relieving the most vulnerable area of the suture - the lower junction of the flaps;
To reduce differences in the length of the edges of the skin wound in the submammary region, the caudal edge of the lateral flap is given an S-shape.

The upper border of the dermal pedicle corresponds to the upper edge of the areola, the lower one is designated 1 cm above the submammary fold. Its width is usually 8-10 cm and can be larger in cases of gigantomastia.

Technique of the operation. After infiltration of soft tissues, the first stage involves forming a pedicle and de-epidermizing it in the usual way. Then, access is made to the subcutaneous fat layer along the de-epidermization border. The pedicle is isolated in the direction of the chest using an electric knife. The thickness of the pedicle at its base should be 8-10 cm, and at the top (under the areola) - at least 3 cm. The wide base of the pedicle ensures normal blood supply and innervation of the areola and nipple by preserving the main feeding vessels and nerves. The pedicle is isolated evenly, avoiding the creation of significant depressions and irregularities, which can lead to a disruption of the blood supply to the nipple-areolar complex.

Then the excess gland tissue is excised and, with the patient in a semi-sitting position, its shape is finally determined. The pedicle is fixed to the upper edge of the skin wound (new border of the areola) at the top with a dermal reverse suture in accordance with the new position of the nipple-areolar complex.

Before finally closing the wound, temporary stitches are applied to “collect” the gland and, if necessary, correct its shape, achieving the desired contour.

The wound is closed by moving the lateral and medial skin-fat flaps to the center of the gland over the de-epidermized part of the flap. The wound suture is multi-row. The sutures on the subcutaneous fat are applied with 3/0 vicryl, the skin is sutured with an intradermal continuous removable suture (4/0 prolene). The wound is drained with tubes with active aspiration of wound discharge.

Postoperative period. Drains are removed on the 2nd-3rd day. Continuous intradermal suture is removed after 2 weeks. Patients wear a tight bra constantly for 2 weeks.

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