Date Published: November 9, 2017
Publisher: Springer US
Author(s): Paul E. Chasan.
Although breast reduction surgery plays an invaluable role in the correction of macromastia, it almost always results in a breast lacking in upper pole fullness and/or roundness. We present a technique of breast reduction combined with augmentation termed “reductive augmentation” to solve this problem. The technique is also extremely useful for correcting breast asymmetry, as well as revising significant pseudoptosis in the patient who has previously undergone breast augmentation with or without mastopexy.
An evolution of techniques has been used to create a breast with more upper pole fullness and anterior projection in those patients desiring a more round, higher-profile appearance. Reductive augmentation is a one-stage procedure in which a breast augmentation is immediately followed by a modified superomedial pedicle breast reduction. Often, the excision of breast tissue is greater than would normally be performed with breast reduction alone.
Thirty-five patients underwent reductive augmentation, of which 12 were primary surgeries and 23 were revisions. There was an average tissue removal of 255 and 227 g, respectively, per breast for the primary and revision groups. Six of the reductive augmentations were performed for gross asymmetry. Fourteen patients had a previous mastopexy, and 3 patients had a previous breast reduction. The average follow-up was 26 months.
Reductive augmentation is an effective one-stage method for achieving a more round-appearing breast with upper pole fullness both in primary breast reduction candidates and in revisionary breast surgery. This technique can also be applied to those patients with significant asymmetry.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.
Breast reduction is an important tool in the plastic surgeon’s armamentarium. There are few plastic surgery procedures that result in as a high level of patient satisfaction. Multiple generations of the technique have resulted in better shape, less scars, and more predictable results [1–6]. However, even with the most proficient and technically advanced breast reductions, there continue to be limitations with respect to the shape of the breast. With time, there is almost always a lack of superior pole fullness . Although many patients are satisfied with the results from the current art of breast reduction, there are a number who request a more “perky” or “round” result and/or desire a breast with a rounder shape and upper pole fullness, a class 3-5/5 based on a breast shape classification system (Figs. 1) . Reductive augmentation is a surgical procedure that has been developed to achieve this type of result (Fig. 2).Fig. 1Breast shape classification: Class 1—appears natural without implant contour, Class 2—appears natural with slight implant contour, Class 3—intermediate in roundness of upper pole, Class 4—round appearance of upper pole, Class 5—maximum roundness of upper poleFig. 2A 54-year-old female G2P2 with 36 G cup breasts who wanted to have large round breasts after breast reduction (sternal notch-to-nipple distance 30 cm). a Preoperative, b 1 month after breast reduction removing 455/585 g, c 6 months postoperatively—satisfactory result, but patient unhappy as she had little upper pole fullness, d 8 months after reductive augmentation (Allergan Style 20, 280 cc placed with excision of 275 g from the right breast and 245 g from the left breast)
Initially, reductive augmentation was offered to patients who desired smaller breasts with more superior pole fullness and anterior projection than could be achieved with standard breast reduction techniques. The selection criteria were expanded to include patients with excess inferior pole breast tissue (pseudoptosis) following prior breast augmentation with or without mastopexy, as well as patients with gross breast asymmetry. Although the procedure had been done for many years, it had undergone a variety of modifications. The start of the study represents the technique in its most recent form.
Between May 2013 and June 2017, 35 consecutive reductive augmentations were performed. Of these, 12 patients had primary macromastia (Figs. 3, 4, 5), while 23 patients had undergone previous augmentation (Figs. 6, 7, 8, 9). Six patients had gross breast asymmetry, defined as a tissue excision of 75 g or greater between breasts (Fig. 10). The average patient age was 45 (range 17–73) years. Patients had an average of 26 months (range 3–48 months) of follow-up. The operative time ranged from 4 to 6½ h.Fig. 3A 52-year-old female G4P3 with 36 DD breasts and grade 3 ptosis (sternal notch-to-nipple distance 29 cm) who desired to be a 36 small D cup with 4/5 in definition. Reductive augmentation was performed removing 335 g bilaterally and placing Allergan SRX 470 cc ultra-high-profile silicone implants bilaterally. Seven months postoperativelyFig. 4Operative sequence of patient in Fig. 2: a placement of right breast implant sizer (320 cc Style 45) via infra-areolar vertical incision, b tailor-tack mastopexy with staples in sitting position, c markings made and staples removed, note superomedial pedicle marked, d initial excision (220 g) before removal, e after removal of specimen—noted thickness of flaps, f lateral and medial flaps after thinning/excision (additional 115 g), g re-stapling, h after secondary mastopexy, i final closure after placing implant (SRX 470 cc) in sitting positionFig. 5A 44-year-old female G1P1 with significant breast asymmetry who desired to be a medium to large C cup with 3/5 in definition. Reductive augmentation was performed removing 500 g from the right breast and 300 g from the left breast, and Allergan Style 45 320 cc implants were placed bilaterally. Eighteen months postoperativelyFig. 6A 37-year-old female G2P2 S/P with previous breast augmentation and mastopexy who developed bottoming out and pseudoptosis. She desired to be a medium to large C cup with 3/5 in definition. Reductive augmentation was performed removing saline implant 275 cc filled to 300 cc from each breast and a tissue excision of 340 g from the right breast and 320 g from the left breast. Allergan Style 45 320 cc implants were placed bilaterally. Three months postoperativelyFig. 7Operative sequence of patient in Fig. 6: a Infra-areolar vertical approach, lateral and inferior capsulorrhaphy, mirror-image capsulotomy, and placement of sizer, b tailor-tack mastopexy in sitting position, c, d tissue excision, e temporary closure, f final on-table result in sitting positionFig. 8A 70-year-old female G2P2 S/P with subglandular breast augmentation and mastopexy 30 years prior with significant “slide down” of her breasts (sternal notch-to-IMC distance of 28 cm and sternal notch-to-nipple distance of 28 cm). She desired to be a medium C cup with 2-3/5 in roundness and significant lifting of her breasts. Reductive augmentation was performed removing CUI saline breast implants 270 cc filled to 275 cc on the right and 300 cc filled to 450 cc on the left. The implants were repositioned in the subpectoral location. An Allergan SRF 325 cc implant was placed on the right and SRF 345 on the left. A total of 230 g of breast tissue was removed from the right breast and 155 g from the left breast. One year postoperativelyFig. 9Operative sequence of patient in Fig. 8: a, b infra-areolar approach, reposition of sizer in subpectoral location. Note elevation of implant mound, c tailor-tack mastopexy. Note significant elevation of IMC and redundancy of inferior pole breast tissue, d, e tissue excision. The patient required undermining of the upper abdomen and elevation of the IMC prior to closure, f final on-table result in sitting positionFig. 10A 17-year-old female G0 with significant breast asymmetry who desired to be a large C cup with 2/5 in definition. Reductive augmentation was performed removing 55 g from the right breast and 290 g from the left breast, and Allergan SRF 385 cc implants were placed bilaterally. One year postoperatively
Several techniques have been described to improve superior pole fullness utilizing either de-epithelialized or parenchymal flaps, or mesh [14, 15], but these have produced inconsistent long-term results at best [7, 16]. Simultaneous or staged breast augmentation with mastopexy has been described [3, 9, 17–19], but these are not associated with large reductions in the inferior pole breast tissue. Notably, the Regnault “minus-plus mastopexy” [20, 21] is a combination of augmentation and mastopexy, involving tissue excision from the lower quadrants and an inferolateral-based flap that is pulled medially to redefine the inframammary crease. Although this procedure does provide more fullness in the upper quadrants than mastopexy alone, the degree of upper pole breast fullness and inframammary crease elevation is limited due to the inferiorly based flap when compared to reductive augmentation. Another approach to achieving upper pole fullness without augmentation has been described by Biggs and Graf [16, 22]. This procedure involves mobilization of a chest wall-based flap of breast tissue passed under a loop of pectoralis major muscle with subsequent mastopexy. Because an implant is not utilized, the degree of fullness and overall roundness of the breasts are less than can be achieved with reductive augmentation. Additionally, because the flap is based inferiorly, there is again limitation in the elevation of the inframammary crease and breast.
Reductive augmentation is a technique for creating a round breast with more upper pole fullness in those patients who are otherwise candidates for breast reduction and desire a specific aesthetic appearance. This procedure is especially helpful in those patients with asymmetry and/or patients with previous breast augmentation with or without mastopexy who develop pseudoptosis and want a more round-appearing breast. The procedure can result in an increase or decrease in overall volume and redistribute the remaining volume into a higher position. Even in those patients who experience minimal reduction in net breast weight, the breast appears to be smaller due both to rounder shape, reduction in the skin envelope, and to redistribution of volume. We have described a technique for a certain subsegment of patients who have larger breasts, ptosis, and who desire a more round-appearing result with upper pole fullness.