Plastics

Fellowship: UCLA Medical Center Program (2017)
Residency: University of Toronto (2013)
Residency: Vanderbilt University Medical Center Program (2016)
Medical School: McGill University Faculty of Medicine (2008)

Patient is a female with severe bilateral breast hypertrophy. She has significant symptomatology related to breast hypertrophy. Specifically, she is experiencing persistent upper back and neck pain that has worsened over time. She also has shoulder grooving from the use of heavy support brassieres and moisture collection at the inframammary folds.

She is a good candidate for bilateral breast reduction surgery to relieve and alleviate the symptomatology that she is experiencing.

We reviewed the risk of surgery that include but are not limited to bleeding, infection, fluid collection (seromas and/or hematoma), delayed wound healing and/or wound dehiscence, abnormal scarring (e.g., hypertrophic and keloid scarring), scar widening, skin necrosis, partial or full-thickness nipple-areolar complex loss, partial or complete loss of sensation to the nipple-areolar complex, sensory changes to breast, chronic pain, injury to adjacent structures/organs/nerves/vessels, fat necrosis, contour abnormality, breast asymmetry, unacceptable cosmetic outcome, deep venous thrombosis/pulmonary embolism, and the possible need for additional surgery in the future. I again explained that breast reduction may require free nipple grafting in cases of large volume reduction or where perfusion of the nipple is insufficient. She understands that free nipple grafting would be performed if circulation to the nipple-areolar complex is compromised. She understands that free nipple grafting results in complete loss of sensation to the nipple-areolar complex and may result in de-pigmentation of the areolar.

The patient was preoperatively marked in the upright position. All questions were answered and consent was signed.

Description of the operation: The patient was taken to the operating room and positioned supine on the operating table. Sequential compression devices were placed on both lower extremities for DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. All bony prominences were padded. After induction of general anesthesia, a timeout was performed with the entire team. The chest area was prepped and draped in the usual sterile fashion.

Attention was first turned to the right breast. The breast was placed under smooth uniform stretch and a 42 mm areolar cookie cutter was used to delineate a new areolar border. Given a relatively short distance between the vertical apex and the initial nipple position, a superomedial pedicle technique was felt to be most appropriate. A superomedial pedicle with 8 cm base was drawn out around this. The breast was first infiltrated with tumescent solution with epinephrine, taking care to stay out of the pedicle. The rest of the markings were incised in a Wise-pattern technique. The skin around the marked areola and along the superomedial pedicle but within the wise pattern was de-epithelized sharply after it was placed under stretch with an Esmarch bandage. The pedicle was first dissected with electrocautery, making efforts to preserve broadly-based parenchymal attachment to preserve vascularity and sensation. The parenchymal excision was carried out next, preserving thick upper breast flaps, with limited undermining of the upper flaps, and leaving a thin layer of fatty tissue above the pectoralis fascia. Parenchymal reduction was mostly done inferiorly and laterally. Care was taken to hollow out the lateral-most portion of the lateral upper breast flap and part of the adjacent subaxillary fat roll to decrease its prominence, though it could not be completely eliminated. This created a cone shaped breast. The superomedial pedicle was freed enough inferomedially to allow transposition of the nipple-areolar complex superiorly to reach the desired position.

Attention was then turned to the left breast and the same procedure was performed.

At that point, both sides were compared for symmetry. Pedicles and flaps were compared and trimmed as needed to ensure uniformity and symmetry. Tissue specimens were then individually weighed for comparison, and sent to pathology for histologic examination. 580 grams of tissue was removed from the right breast and 540 grams from the left breast. Both breast pockets were then copiously irrigated with antibiotic saline solution and inspected, and hemostasis was confirmed.

A temporary finding suture was placed at the 12 o'clock position of the pedicle bilaterally. The central inset position of the vertical limb was determined to optimize shape and symmetry, and the upper breast flaps were secured at this point using 2-0 PDS sutures at the Scarpa's fascial level bilaterally.

In this case, deep central pillars sutures and additional parenchymal medializing sutures were beneficial laterally to assist in centralizing breast volume from the periphery, using interrupted 2-0 PDS sutures bilaterally.

Inset at the skin level was also carried out bilaterally so as to medialize the lateral upper breast flaps substantially, thus reducing central tension and providing a better shape with good projection. A provisional closure was carried out with skin staples bilaterally to assess shape and symmetry. The patient was then brought up to the seated position intraoperatively and inspected, and adjustments of the closure were made; good volume and shape symmetry was confirmed. The new nipple-areola complex positions were then placed visually and measured to ensure symmetry, using a 42 mm areolar cookie cutter. In this case, they were marked 5 cm from the IMF for a 7cm nipple position bilaterally. Attention was paid to avoid excessively high position, anticipating later relaxation of the lower pole. The patient was then returned to a supine position.

The areolar cutout was first de-epithelialized bilaterally, and release of the dermis and some parenchyma was carried out with electrocautery. The nipple-areola pedicle was then exteriorized bilaterally and parachuted back down to the surrounding tissues with interrupted 3-0 Monocryl sutures for the deep dermis followed by a running subcuticular 4-0 Monocryl. The vertical limbs were then closed bilaterally with interrupted 3-0 Monocryl sutures for the deep dermis and running subcuticular 4-0 Monocryl suture. Then, the horizontal limb closure was performed bilaterally. In this case, the the upper breast flaps were secured at the Scarpa's fascial level using a few interrupted buried 2-0 PDS sutures to allow better shape of the lateral breast border. The horizontal limbs were closed with interrupted 3-0 Monocryl sutures for the deep dermis and running subcuticular 3-0 Monocryl Stratafix suture. Both nipple-areola complexes appeared pink and viable after closure was completed.

The breasts were cleansed with normal saline. Mastisol and steristrips were used for dressings bilaterally around the NACs. Dermabond was applied to the remainder of the incisions. She was then placed into a surgical bra with fluffs. The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. All counts were correct at the end of the case. I was present for the entire procedure.