Operations with minor and moderate degree of mammary hypertrophy

With an insignificant and moderate degree of mammary hypertrophy, the choice of operational techniques for their reduction should be made taking into account not only the volume of glands, but also the degree of their ptosis.

When the initial distance from the areola to the submammary fold does not exceed 12 cm, a good result is achieved using vertical technique of reduction mammoplasty. This technique allows to form only a vertical postoperative scar and a scar around the areola, and also to achieve a stable result.

Vertical reduction mammoplasty

The principle of the operation consists in the central resection of breast tissue (skin, fatty and glandular tissues), transposition of the nipple-areola complex on the upper dermal leg and the completion of the operation by superposition of the vertical seam.

Preoperative marking is performed when the patient is standing. Mark the median line, submammary fold, determine the new position of the nipple, which is located just above the projection of the level of the submarine fold (on average, 20 cm from the jugular notch along the line connecting the tenderloin and nipple in a new position.

Then the vertical axis of the mammary gland is marked, which is usually 10-12 cm from the median line. On this line are oriented in determining the lateral boundaries of the resected skin.

After that, the gland is moved medially and a line is applied to the displaced tissues, which must coincide with the vertical axis. This is the outer boundary of the resection. Then the gland is laterally shifted and the internal border of the resection is determined in the same way. The lines of the outer and inner boundaries smoothly join each other at a point located 4-5 cm above the pectoral fold, which will correspond to the lower limit of resection.

The next step is a curved line that indicates the edge of the cutaneous wound around the new areola. The upper point of this line is located 2 cm above the new localization of the nipple. The length of the curvature should not exceed 16 cm. This line connects two vertical lines.

In the designated boundaries of the marking there is a de-epidermis field, the lower edge of which is located 2-3 cm below the level of the nipple-areolar complex.

Operation technique. The patient is injected into anesthesia and, by folding the operating table, is placed in a semi-sitting position. The skin around the areola within the upper flap is superficially infiltrated with a 0.5% solution of lidocaine supplemented with adrenaline. This facilitates subsequent de-epidermisation. The resected part of the mammary gland is infiltrated to the full depth.

The operation begins with de-epidermisation of the marked area of the skin. Then, through the external and internal boundaries of the marking, a cut of the skin and subcutaneous fat is done at a depth of 0.5 cm, peel the skin with a thin (0.5 cm) layer of fat from the gland.

The boundaries of the detachment: down to the submammary fold, inside and to the outside - to the lateral borders of the base of the breast and up to the level of the lower edge of the new areola. It is important to note that the superficial detachment of the skin-fat flap allows the skin to contract after the operation. A thicker layer of fiber prevents this process, and after surgery, sagging of the skin in the lower part of the gland can be observed.

Next, the gland is peeled from the chest wall from the bottom upwards from the level of the submammary fold to the upper border of the mammary gland. The width of the detachment zone should not exceed 8 cm (in order to maintain the lateral sources of the gland).

The next step is the resection of the gland tissue. With moderate hypertrophy, the resection of glandular tissue is usually performed on the marked boundaries of removal of excess skin. With more pronounced hypertrophy, the zone of resection of glandular tissue is widened towards the nipple and areola, while the thickness of the de-epidermis flap is at least 2-3 cm.

After removal of excess tissue, the upper part of the gland is additionally fixed to the periosteum of the II or III ribs and behind the chest fascia by a suture of non-absorbable material. Then the edges of the remaining glandular tissue are brought together and stitched together.

After fixing the areola in its new position to the edges of the cutaneous wound proceed to close the vertical part of the wound. To do this, temporary seams (from top to bottom) are applied to the edges of the skin and assess whether additional resection of the tissues is required. If necessary, stepping aside from the first seam line, additional seams are applied to the skin, as a result of which the shape of the gland improves. If the surgeon is satisfied with this result, he marks the boundaries of the new seam line with methylene blue and passes 3-4 horizontal lines across them, numbering them from two sides. Then the sutures are opened and the final resection of the edges of the skin wound is made in accordance with the final markings. Next, double-layered final seams are applied to the skin, comparing the horizontal lines. Subcutaneous immersive suture made of non-absorbable material ensures close contact of the edges. The operation is completed by the application of an intracutaneous continuous removable suture and matching sutures to the skin (4/0). In this case, the seam should be located on the lower pole of the gland. Note that after moving the breast tissue up, the length of the skin wound begins to significantly exceed the length of the lower pole of the gland. Therefore, an important element of the final stage of intervention is the corrugation of the skin wound after the application of the intradermal suture removed. As a result, its length decreases to 5-6 cm. The wound is drained with tubes.

The peculiarity of this operation is that at the end of the intervention the upper part of the gland has a convex shape, and the lower part is flat. However, in the postoperative period, the skin gradually spreads. The final form of the gland is formed after 2-3 months.

Cutaneous matching sutures are removed after 5 days after the operation. Continuous intradermal suture is removed after 2 weeks. The bra is not worn for 3 months, until the gland takes its final form.

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