Operations with severe mammary hypertrophy

With pronounced hypertrophy of the mammary glands, only 500 to 1200 g of tissues are resected. In this case, good results are obtained by the use of operational techniques with the formation of the lower tissue leg. In shape, it resembles a pyramid, and therefore R. Goldwyn called this method of reduction mammoplasty pyramidal technique. The advantages of this operation include the provision of reliable blood supply to the nipple-areolar complex and the preservation of its sensitivity. A considerable volume of tissues can be removed, and the areola moved to a new position up to a distance of 20 cm.

Marking is done with the patient's vertical position. The new position of the nipple-areola complex is determined by the line passing from the middle of the collarbone through the nipple. It is located at the level of the pectoral fold just below the normal position of the nipple and areola, as the skin of the gland after the operation is shortened and the areola rises to its natural position.

Using a special template, which is a wire curved in the form of a keyhole, a new place of areola is marked and the vertical boundaries of the medial and lateral skin-fat flaps coming from it are marked. The diameter of the areola is 4.5-5 cm. Vertical borders of the flaps are located somewhat at an angle such that the length of the horizontal edge of the lateral and medial flaps is the same. At the same time, deviation of vertical flap boundaries should not be significant in order to avoid excessive tension at the edges. The length of the vertical edge of the flap should not exceed 5 cm.

To achieve the maximum aesthetic result of surgery and prevention of peripheral circulation disorders in skin flaps, the following techniques should be used:

• in the center of the lower edge of the wound, a dermal protrusion can be made, unloading the most vulnerable zone of the suture-the bottom joint of the graft;
• to reduce the differences in the length of the edges of the cutaneous wound in the pectoral area, the caudal margin of the lateral flap is attached to the S-shape.

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

Operation technique. After infiltration of soft tissues, the first stage forms the leg and de-epidermalizes it in the usual way. Further, access is made to the subcutaneous fat layer along the de-epidermis boundary. The leg is isolated in the direction of the chest, using an electron knife. The thickness of the pedicle at its base should be 8-10 cm, and at the apex (under the areola) - not less than 3 cm. The wide pedicle base provides normal blood supply and innervation of the areola and nipple at the expense of maintaining the main feeding vessels and nerves. The knife 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 tissue of the gland is excised and in the position of the patient the hemisphere finally determines its shape. The leg is fixed to the upper edge of the skin wound (the new areola border) at the top by the dermal back suture in accordance with the new position of the nipple-areolar complex.

Before finally closing the wound, temporary seams are applied in order to "assemble" the gland and, if necessary, adjust its shape, achieving the desired contour.

The wound is closed with the displacement of the lateral and medial skin-fat flaps to the center of the gland above the de-epidermis part of the flap. The seam on the wound is multi-row. The sutures on the subcutaneous fatty tissue are superimposed with vichril 3/0, the skin is sewn with the intradermal continuous suture removed (4/0 spill). The wound is drained with tubes with active aspiration of the wound separable.

Postoperative period. Drainage is removed on the 2-3rd day. Continuous intra-dermal suture is removed after 2 weeks. Patients constantly wear a dense bra for 2 weeks.

[1], [2], [3], [4], [5], [6], [7]