Reduction mammoplasty: history, classification of mammary gland hypertrophy, indications

• History

The history of the development of methods of reduction mammoplasty takes its origins from ancient times and reflects the surgeons' desire to find an operation method that is reliable, left as few as possible post-operative scars and provided for a sufficiently long time the desired shape and position of the mammary glands. This article touches upon only those methods that influenced the formation of modern principles of reducing mammary plasticity.

In 1905 H.Morestin described a large disk-like resection of the base of the breast.

For the first time in 1908 JJDehner pointed out the need for fixing the gland tissue retro-mammally and described the technique of the upper semilunar resection with subsequent fixation of the gland tissue behind the periosteum of the 3rd rib.

In 1922, M. Thorek proposed a technique for reducing the mammary gland with a free transplantation of the nipple-areola complex, like a full-layer skin flap. This operation has been recognized by many plastic surgeons and is currently used in gigantomastia.

In 1928, H. Biesenberger [3] formulated the basic principles of the technique of reduction mammoplasty, which assumed 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 nutrition of the nipple-areolar complex due to the vessels located directly in the dermis, proposed a reduction mammoplasty operation with the formation of a dermal horizontal leg, which ensured reliable feeding of the areola and nipple .

In the future, the improvement of the method of reducing the mammary glands was reduced to various modifications of the formation of dermal legs and a decrease in postoperative scars.

The possibility of isolating the nipple-areola complex on the lower feeding stem was substantiated by D.Robertson in 1967 and was widely promoted by R.Goldwin, who called it the pyramidal technique of reducing the mammary glands.

C.Dufourmentel and R.Mouly (1961), and then P.Regnault (1974) proposed a method of reduction mammoplasty that allowed the postoperative scar to be located only in the lower part of the gland and excluded the traditionally running scar from the gland to the sternum.

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

• Classification of mammary gland hypertrophy

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

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

The increase in mammary glands in adulthood can occur with pregnancy, general endocrine disorders, obesity. Currently, mammary gland hypertrophy is classified according to the following indices.

• Indications and contraindications for surgery

Heavy, pendulous mammary glands can cause a woman both physical and psychological suffering. One hypertrophy of one mammary gland is possible. Discomfort due to excessive volume and mass of 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 deformities of the spine. It is often possible to see cicatricial grooves on the forearms, arising from the excessive pressure of the strapless bra. Hypertrophy of the mammary glands can be accompanied by chronic mastitis and mastopathy with or without pain syndrome. Often, women complain about maceration and intertrigo in the area of the pectoral fold, which are difficult to treat.

Often the main reason for the patient to reduce the volume of the mammary glands is the problem of clothing selection.

A specific contraindication to reduction mammoplasty may be the patient's disagreement with the presence of postoperative cicatrices and a change in the sensitivity of the nipple-arenaceous complex, as well as with the possible restriction of lactation.

• Planning an operation

In addition to clinical and laboratory examination, a consultation of the oncologist-mammologist and mammogram (according to indications) should be included in the complex of mandatory preoperative measures.

When the patient is examined, the proportions of the body, the size of the glands and the thickness of the subcutaneous fat layer are evaluated, the main parameters are measured and the sensitivity of the nipple and areola is checked (especially with the iron surgeries performed earlier).

After the examination, the surgeon should determine, due to predominantly what tissue hypertrophied iron, the degree of her ptosis, the tour of the mountains and the condition of the skin covering the gland, the presence of strips of skin stretching.

It is generally accepted to estimate the volume of mammary glands by the size of a bra. However, in most cases, women with large breasts select a bra with a volume of cups smaller by size, but with a chest circumference larger by size to make the breast flatter. Therefore, when planning the number of tissues to be removed, the surgeon should not be guided by the size of the bra worn by the patient. The true size of the bra is determined by two measurements. The patient in the bra is in a sitting position. At first, the circumference of the chest is measured with a centimeter tape at the level of the axillae and above the upper border of the glands. Then, a measurement is made at the nipple level. The value of the circumference of the chest is subtracted from the value of the second dimension. If the difference between the two measurements is 2.5 cm, the volume of the breast will correspond to a "cup" of a bra with a size A, if from 2.5 to 5 cm, then with a size B, if from 5 to 7.5 cm, then with size C, if from 7.5 to 10 cm, then with a size D, if from 10 to 12.5 cm, then with a size of DD. For example, 85 cm is the circumference of the chest, 90 cm is the circumference of the breast at the level of the nipples, in this case the bra size will be 85 V.

P. Regnault (1984) defines the excess volume of mammary glands with their decrease by one size depending on the circumference of the chest.

So, if the bra size is 90 D and the patient wants to get 90 V, then 400 g of mammary gland tissue should be removed.

The volume of tissues to be removed, the type of hypertrophy and the condition of the skin of the gland affect the choice of the optimal surgical technique

In each 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 peculiarities of the postoperative course, possible complications (hematoma, necrosis of adipose tissue and nipple-areolar complex) and long-term consequences (changes in nipple sensitivity and areola, lactation limitation, glandular shape change).

Patients with juvenile hypertrophy should be warned about the likelihood of a relapse.

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