Reduction mammoplasty: history, classification of breast hypertrophy, indications

• Story

The history of the development of reduction mammoplasty methods originates from ancient times and reflects the desire of surgeons to find a method of surgery that would be reliable, leave as few postoperative scars as possible and provide the desired shape and position of the mammary glands for a sufficiently long time. This article touches upon only those methods that influenced the formation of modern principles of reduction mammoplasty.

In 1905, H. Morestin described a large discoid resection of the base of the mammary gland.

For the first time in 1908, JJ Dehner pointed out the need for retromammary fixation of the glandular tissue and described the technique of upper semilunar resection with subsequent fixation of the glandular tissue to the periosteum of the third rib.

In 1922, M. Thorek proposed a technique for reducing the mammary gland with a free transplant of the nipple-areolar complex, similar to a full-thickness skin flap. This operation has gained recognition among many plastic surgeons and is currently used for gigantomastia.

In 1928, H. Biesenberger [3] formulated the basic principles of reduction mammoplasty, which involved three main stages: resection of glandular tissue, transposition of the nipple-areolar complex, and excision of excess skin. Until 1960, this operation was the most common method of reduction mammoplasty.

J.Strombeck (1960), based on the concept of E.Schwarzmann (1930) on the nutrition of the nipple-areolar complex due to vessels located directly in the dermis, proposed a reduction mammoplasty operation with the formation of a dermal horizontal pedicle, which ensured reliable nutrition of the areola and nipple.

Subsequently, improvements in the technique of breast reduction were reduced to various modifications of the formation of dermal legs and the reduction of postoperative scars.

The possibility of isolating the nipple-areolar complex on the lower pedicle was substantiated by D. Robertson in 1967 and was widely promoted by R. Goldwin, who called it the pyramidal technique of breast reduction.

C. Dufourmentel and R. Mouly (1961), and then P. Regnault (1974) proposed a method of reduction mammoplasty, which allowed the postoperative scar to be placed only in the lower outer sector of the gland and excluded the traditional scar that runs from the gland to the sternum.

C.Lassus (1987), and then M.Lejour (1994) proposed reduction mammoplasty, after which only a vertical scar remained, located in the lower half of the mammary gland.

• Classification of breast hypertrophy

The normal development of the mammary glands is influenced by various hormones that regulate this complex process.

A significant increase in mammary glands occurs already during puberty, when their mass can reach several kilograms. The mechanism of gigantomastia development in adolescence is complex and not fully understood.

Enlargement of mammary glands in adulthood can occur during pregnancy, general endocrine disorders, obesity. Currently, hypertrophy of mammary glands is classified according to the following indicators.

• Indications and contraindications for surgery

Heavy, sagging mammary glands can cause both physical and psychological suffering to a woman. Hypertrophy of one mammary gland is possible. Discomfort due to excessive volume and mass of the glands is the main indication for reduction mammoplasty in most patients. Some women complain of pain in the thoracic and cervical spine, which is a consequence of concomitant osteochondrosis and static deformations of the spine. Often, one can see cicatricial grooves on the shoulders, which arise from excessive pressure of bra straps. Hypertrophy of the mammary glands can be accompanied by chronic mastitis and mastopathy, both with and without pain syndrome. Often, women complain of maceration and diaper rash in the area of the inframammary fold, which are difficult to treat.

Often the main reason that prompts a patient to reduce the volume of her mammary glands is the problem of choosing clothes.

A specific contraindication to reduction mammoplasty may be the patient’s disagreement with the presence of postoperative scars and changes in the sensitivity of the nipple-areola complex, as well as possible limitation of lactation.

• Planning the operation

In addition to clinical and laboratory examination, the complex of mandatory preoperative measures must include a consultation with an oncologist-mammologist and mammography (if indicated).

When examining the patient, the body proportions, the ratio of the size of the glands and the thickness of the subcutaneous fat layer are assessed, the main parameters are measured and the sensitivity of the nipple and areola is checked (especially if previous interventions on the gland have been performed).

After the examination, the surgeon must determine which tissue is predominantly responsible for the hypertrophy of the gland, the degree of its ptosis, the turgor and condition of the skin covering the gland, and the presence of stretch marks on the skin.

It is common practice to estimate the volume of the mammary glands by the size of the bra. However, in most cases, women with large mammary glands select a bra with a cup volume one size smaller, but with a chest circumference one size larger in order to make the breasts flatter. Therefore, when planning the amount of glandular tissue to be removed, the surgeon should not rely on the size of the bra that the patient wears. The true bra size is determined by two measurements. The patient is in a sitting position in a bra. First, the chest circumference is measured with a tape measure at the level of the armpits and above the upper border of the glands. Then, the measurement is taken at the level of the nipples. The chest circumference is subtracted from the second measurement. If the difference between the two measurements is 2.5 cm, then the volume of the mammary gland will correspond to the "cup" of a bra with size A, if from 2.5 to 5 cm, then with size B, if from 5 to 7.5 cm, then with size C, if from 7.5 to 10 cm, then with size D, if from 10 to 12.5 cm, then with size DD. For example, 85 cm is the circumference of the chest, 90 cm is the circumference of the chest at the level of the nipples, in this case the bra size will be 85 B.

P. Regnault (1984) defines excess volume of mammary glands when they are reduced by one size depending on the chest circumference.

So, if the bra size is 90 D and the patient wants to get 90 B, then 400 g of breast tissue must be removed.

The volume of tissue removed, the type of hypertrophy and the condition of the skin of the gland influence the choice of the optimal surgical technique.

In each specific case. When removing more than 1000 g, it is advisable to prepare auto-blood.

Before the operation, the patient is informed about the configuration and location of postoperative scars, the characteristics of the postoperative course, possible complications (hematoma, necrosis of adipose tissue and the nipple-areola complex) and long-term consequences (changes in the sensitivity of the nipples and areola, limited lactation, changes in the shape of the gland).

Patients with juvenile hypertrophy should be warned about the possibility of recurrence.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]