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Mammaplasty: Indications, technique, and complications
M A M M A P L A S T Y : INDICATIONS, T E C H N I Q U E , AND COMPLICATIONS By SIR ARCHIBALDMCINDOE, C.B.E., M.Sc., F.R.C.S., F.A.C.S. Surgeon-in-Charge, Queen Victoria Hospital, East Grinstead and THOMAS DEE REES, M.D. Formerly Senior Registrar and Marks Fellow in Plastic Surgery, Queen Victoria Hospital, East Grinstead MAMMAPLASTY is, in its modern sense, an operation generally accepted by profession and public alike. In former times the only alternative offered by the general surgeon to the patient suffering from a deformity or gross enlargement of the breast was amputation. This regrettable procedure, justifiable only in the case of cancer, should now have no place in the surgery of benign lesions. But it is equally clear that reconstruction of the breast should require from the surgeon a considerable understanding of reparative principles and should impose upon him the responsibility for creating an organ of good shape and contour, correctly placed and with a minimum of scarring--in short, a cosmetically desirable breast--in addition to one in which function is preserved. To be physically acceptable is a normal desire, and in the evolution of a satisfactory operation it should be possible to promise the patient :-I. That breasts of normal size and contour can be constructed in one stage, with few exceptions, whatever the original size. 2. That, provided sufficient breast tissue is available, lactation will be normal and nipple sensation preserved in at least 5o per cent. of patients. 3. That, if chronic mastitis is present, the pain can be reduced proportionate to the reduction in volume of the affected gland tissue. 4. That the breasts will not subsequently enlarge or slump. 5- That scarring will be limited in extent and largely concealed by the normal submammary fold. A point of some importance is the extent to which the reconstructed breasts tend to " d i s h " or " slump " post-operatively. This is due to two factors. Firstly, failure to construct a properly fitting skin brassiere around the subjacent cone of breast tissue and, secondly, allowing the breast tissue to slip behind the 'transverse submammary incision. This report presents 347 consecutive cases with a total of 381 operations on 687 breasts carried out by the senior writer over the past twenty-five years. The operation to be described and recommended represents the end result of experience with these cases and an improvement on techniques previously described (Gillies and Mclndoe, 1939; Mclndoe, 195o). The cases have been analysed independently by the junior writer, so that the end results and complications are faithfully stated. Since the advent of controlled hypotensive anmsthesia in 195o all cases have been operated on by a modification of this technique (Enderby, 195o and 1952; Mclndoe, 1956). This is concerned with the level of blood-pressure maintained 307
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during the operation. It has been found that a systolic blood-pressure of 80 to 90 ram. Hg is sufficient to limit the majority of operative bleeding without at the same time increasing the liability to post-operative hmmatoma formation. As will subsequently appear this is by far the most common post-operative complication. INDICATIONS FOR OPERATION
In the vast majority the main indication for operation is excessive weight of one or both breasts. Patients with heavy pendulous breasts are handicapped mentally and physically. In young women embarrassment increasing to genuine neurosis may seriously affect their adjustment to normal social life. Particularly is this so on the dance floor, in the swimming pool, or during those complicated emotional phases of womanhood which should lead to the wedding bells. In later years poor posture may lead to kyphosis or cervical arthritis (Conway, 1952) with chronic exhaustion and lassitude. Painful grooving of the shoulders from brassiere supports, together with unpleasant submammary intertrigo, produce a condition which few women wish to tolerate. Unilateral enlargement of one breast or atrophy of the other may determine operation. Finally, painful chronic mastitis, so often a feature of mammary hypertrophy, can be adequately treated by mammaplasty rather than the commordy advised but completely unjustifiable bilateral amputation. AGE INCIDENCE
The youngest patient in this series was 15, the oldest 62. Eight per cent. of the patients were in the second decade of life, 27 per cent. in the third, 27 per cent. in the fourth, 18 per cent. in the fifth, and 18 per cent. in the sixth. It is of interest that the largest amounts of tissue were resected in the young, particularly those with virginal hypertrophy or true gynmcomastia. TABLE I Types of Cases Type/.--Long, flabby breasts with or without glandular
35 hypertrophy (adolescent type) Type//.--Broad, heavy, obese breasts 2oi Type IIL--Pendulous, sac-like, following pregnancy 87 and/or obesity reduction Type IV.--Virginal hypertrophy (true gynmcomastia) I7 Type V.--Asymmetry (unilateral micromastia) 7 CLASSIFICATION
Table I represents a classification of the patients according to their physical characteristics (Mclndoe, I95O). Easily the largest number (2Ol) were Type II, broad heavy breasts unrelated to any other observable factors than obesity and glandular insufficiency. Operation was indicated because of excessive weight which limited social and physical activity. Eighty-seven were Type III following repeated pregnancies or weight reduction. Here the skin had been permanently stretched by glandular or fatty enlargement, indicated by linem striae, with descent of the breasts to the mid-abdomen or even lower. Disappearance of fat or atrophy
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of the glandular element leaves a loose pendulous sac often amounting to a positive deformity. Thirty-five were Type I. There is little difference between Type I and Type III except that the former occur in the young and in the absence of general obesity. Glandular imbalance is almost certainly the cause. Seventeen were Type IV (true gynmcomastia) and were often grotesque. Many of these patients had had extensive hormone therapy without the slightest benefit. The largest amounts of tissue were removed in this group, in one girl of I5 years 18 lb. from the two sides. Seven cases were Type V in which unilateral enlargement or micromastia was present. TABLE
II
Primary Operations Total number of cases, 3 4 7 Bilateral Unilateral General anaesthesia Controlled hypotension'
340 7 276 7I
Total number of complications, 39 General anaesthesia Controlled hypotension'
32 7
Glandular operation performed Lateral resection (Biesenberger) Bipedicle (Gillies-McIndoe) . Inferior wedge resection Free nipple transplant .
337 5 3 2
Skin excision performed Transverse ellipse (Passot) Inverted " T " (McIndoe)
IO 337
PRIMARY
OPERATIONS
Two general types of operation have been described. Firstly, those in which the nipple is transplanted freely to a reconstructed breast and in which function is entirely neglected, and secondly those in which the nipple is attached to a breast pedicle and function is preserved. Free nipple transplants were carried out in two cases only. The writers regard this method as cosmetically inferior and physiologically unsound and have abandoned it. It is possibly applicable to older women in states of extreme obesity but rarely, if ever, in the young or middle-aged. In the remaining 345 patients one or other of the pedicled methods was used. In a previous publication (Gillies and McIndoe, I939) a report was made on a bipedicled operation consisting of excision of the central superior portion of the gland and elevation of the remaining mammary tissue on medial and lateral pedicles. This method has been extensively utilised by Ragnell. As seen in Table II, five of these operations were performed and the method then abandoned because of uncertainty with the blood supply of the nipple and the frequency of secondary operations. Wedge resections were carried out in five cases where little elevation was required. This type of operation is more useful as a secondary procedure. The great majority of primary operations (337) were done by a modification of the original Biesenberger (1935) operation in one stage. The modification consists
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(a) in the formation of a medial glandular flap carrying the nipple at its apex with resection of the lateral and axillary elements : the blood supply is made entirely safe by preservation of a " m e s e n t e r y " along the inferior border of the pectoralis major containing branches of the lateral thoracic artery; (b) in the construction of a firmly fitting skin brassiere so attached inferiorly to the chest wall that the breast tissue cannot slip behind the transverse scar. This operation has given such satisfactory results that it will be presented in some detail (Figs. I to 5).
'/zto z in.
\
Ski n
FIG. I Operative technique. OPERATIVE TECHNIQUE
The patient is anmsthetised, intubated, and placed on the operating table in the classical semi-sitting position with the arms akimbo. Controlled hypotensive ana:sthesia is used at a pressure of 8o mm. Hg. After preparation of the skin the operative area is draped to give a good general view of both breasts in relation to the shoulders, the sternal notch and the xiphoid. It is important that the shoulders should be kept square so that the nipple positions can be accurately determined. The landmarks are measured with callipers and compass and checked repeatedly throughout the operation. Depending on the width of the shoulders, the size of the thoracic cage, and the age of the patient the nipples are situated
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7½ to 9{ in. from the sternal notch and 4~ to 6½ in. from the xiphoid. The intersection of the two circles described by the callipers settles the point roughly, but it is clear that the operator's judgment will have much to do with the final positioning. The inter-nipple distance should rarely be less than io to Ii in. /
FIG. 2 Operative technique.
and the nipples should eventually end at the apex of the breast cone pointing forwards and outwards (Fig. I, a). The nipples themselves are then tightly stretched peripherally by the assistant's hands while the areola is circumscribed with compasses. The diameter of the areola is about I½ in., but this, too, varies with the size of breast to be constructed. The skin is split for a distance of at least ~in. round the nipple, so that the periareolar plexus of nerves and vessels and the areolar smooth muscle fibres are preserved. This is an important step and upon the care with which it is carried out will depend the life and sensitivity of the nipple. The vertical skin incision is then carried down to the submammary groove
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and upwards to the presumptive position of the new nipple. The substance of the breast is then dissected away with large dissecting scissors from the medial and lateral skin flaps so formed. Denudation of the breast is extensive, particularly upwards where it should reach to the second rib. By this means a circular base / /
FIG. 3 Operative technique.
for the new cone of breast tissue is established which will be neither too large nor too small. It is rarely sufficient until the perforating branches of the thoracic axis are divided. Having thus denuded the entire breast substance, the~requisite amount of tissue is resected in an S-shaped fashion according to the Biesenberger technique with one important modification. Great care is taken to preserve the medial attachment of the breast pedicle along the lower edge of the pectoralis major. This so resembles a " m e s e n t e r y " that it has thus been designated (Fig. 3, i and j). It contains branches of the lateral thoracic artery not hitherto considered
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important. The writers believe that sacrifice of this considerable blood supply is a common cause of breast tissue necrosis. The freed portion of the breast pedicle is then rotated superiorly and lightly sutured with plain catgut to form a cone of breast tissue and fat. It is important that this approximation to complete the general shape be carried out without any vascular embarrassment (Fig. 3, k and l). A skin hook is then placed at the upper end of the vertical incision (where the new nipple will lie), and this is drawn strongly forwards. The breast cone is
J
FI~. 4 Operative technique.
pushed into the tent of skin so formed and the medial and lateral skin flaps are wrapped around its inferior surface and snugly held there by the application of a large, smooth, curved Doyen's intestinal clamp (Fig. 4, m and n). It is at this moment that the skin brassiere is correctly formed, and failure to judge it accurately will result in poor shape. The skin is manipulated through the clamp tintil the breast cone is tightly clothed with skin, after which the excess below the clamp is excised and the skin edges carefully sutured with fine silk (Fig. 4, o). The submammary excess of skin now lying transversely in the submammary groove is excised as economically as possible. To effect this it is removed by an oval cut,
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thus making the shortest transverse scar in the groove. These incisions on each side should end up identical in length and symmetrically placed (Fig. 5, s). They are anchored to the costal fascia by four heavy silk sutures which serve to secure the submammary transverse incisions to the chest wall and so prevent sagging of the breast tissue below this line. " Dishing " of the breast is one of the most
,
/. J
\\,
"'"'"
Apeo undermined FIG. 5 Operative technique.
common post-operative sequela: of this operation and can be easily controlled in this way. At this stage an appropriate circle of skin is marked ou{ for excision on the apex of the skin brassiere. This is done after careful rechecking of measurements both from the sternal notch and the xiphoid to ensure symmetry (Fig. 4, P). It is well at this stage for the operator to stand at the foot of the table and visually check the location of the nipples and the general shape of the breasts. If these are satisfactory the circular piece is excised, the nipple extruded and sutured into
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position with fine silk. The diameter of the areola when stretched should equal that of the skin excised from the apex. After this the remaining incisions are meticulously finished with fine silk and terminal excesses removed in the usual fashion. Soft rubber drains are inserted medially and laterally in the lower transverse incision to drain the superior and inferior spaces. The same procedure is carried out on the opposite side and a pressure dressing to be left on four days is applied. All sutures except the heavy tension sutures in the transverse incision are removed by stages beginning on the fifth post-operative day with the periareolar sutures. The heavy sutures remain in for ten to twelve days to ensure a firm fibrous attachment of the scar to the chest wall. COMPLICATIONS
Few papers dealing with this subject have dealt with complications, though Conway (I952) recently reported twenty-two in I Io cases of mammaplasty of all types. Ragnell has also reported his complications (Ragnell, i946). This paper presents all complications encountered, no matter how trivial. These are shown in Table III and are self-explanatory. They have been as far TABLE
III
Complications Number of Cases Operated. Complication.
General Anaesthesia.
Heematoma (bilateral) . Haematoma (unilateral) . . Total nipple loss due to h ~ e m a t o m a * Partial nipple loss due to h~ematoma Abscess-infected h~ematoma . Partial nipple loss (unilateral) without haematoma Partial nipple loss (bilateral) without hrematoma Marginal slough of skin flaps Partial wound separation without slough Diffuse local sepsis . . Local fat necrosis with sinus tract . Cerebral thrombosis or embolism . " Dry"
pleurisy
.
Percentage of total number of cases total
3 2
II I
4 I
2 I
I
3 5
I I
2 2 I I
Total
Percentage of operations
Total. Hypotensive.
nttmber
of
32
7
39
II.6
9'9
II'2
IO ' 5
8.9
io'2
* Nipple sloughs associated with small subareolar haematomas.
as possible accurately and independently assessed by the junior writer and accepted as such by the senior.
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The cases are divided into those operated under controlled hypotension and those done previous to 195o under general ana:sthesia. As seen from Table III, thirty-two cases or I 1.6 per cent. of the 276 cases operated on prior to controlled hypotension developed some sort of complication. Following the advent of hypotension in 195o , seventy-one cases have been operated, with seven complications (9"9 per cent. of cases and 8"9 per cent. of the total number of hypotensive operations). This is a significant lowering of the complication rate. Ha:matomata have particularly decreased. There has been only one case of minimal nipple slough since hypotension was adopted. Of all post-operative complications, ha:matoma has been the commonest. Massive ha:matoma is easily recognised and should be dealt with by immediate operation, complete evacuation of the clot, resuturing of the wound with drainage. The smaller localised ha:matoma, on the other hand, is less often recognised but can be the seat of serious trouble. We wish to emphasise one point brought out in this study. The single case of complete nipple slough and five of the seven cases of partial loss were associated with small, localised para-areolar ha:matomata. It appears, therefore, that post-operative circulatory difficulties of the nipple are rarely due to primary circulatory insufficiency; ha:matoma is most often responsible by compression of the circulatory tree. In the past, attention to this matter has been directed towards preserving nipple blood supply, giving rise to differences of opinion in the technique of gland resection. We feel that ha:matomata should be diligently searched for at the first appearance of nipple distress. If these are found, and evacuated early, undoubtedly some of these nipple disasters would be avoided. The remaining complications are listed and are largely self-explanatory. The case of hemiplegia occurred twelve hours after operation. Subsequent studies did not reveal an anomaly of the vascular tree to the brain, and it must be assumed that a cerebral embolism was responsible. The patient recovered with minor sequela:. The patient with fibrinous pleurisy was investigated and no a:tioiogy determined. She recovered. The fatality rate was nil. The term " f a t necrosis " is misleading. It usually occurs to some degree in the presence of ha:matoma or inflammation. It can occur alone, with or without a slough or sinus tract. It can prolong convalescence considerably due to the time taken for the sloughing fibrous tissue to separate. Small areas may be left to heal spontaneously, but if the slough is extensive prompt excision i s the best treatment. SECONDARY OPERATIONS
Table IV tabulates all secondary procedures, including those patients who had primary surgery elsewhere. These include immediate operations for complications and delayed reconstruction of defects secondary to complications-i.e., skin loss, nipple loss, etc. In addition, secondary revision of scars and remodelling are listed. It is again of significance to note the decreased number of secondary operations necessary since the advent of controlled hypotension. The ease of operating in a bloodless field permits more careful attention to detail before fatigue from a long operation blunts the senses of the operator.
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TABLE IV Secondary Operations
Scar revision R e m o d e l l i n g (gland) Reposition nipples . Excision w o u n d slough Excision nipple slough . . . Excision of o p e n areas a n d resuture R e m o d e l l i n g of result operated elsewhere E v a c u a t i o n hzematoma . N i p p l e reconstruction w i t h free graft ( S - T i Total
Controlled Hypotension.
General Anaesthesia.
i
7
•"
4
,..
I
...
2
.,,
I
I
I
3 2
z 8
...
I
7
27
DISCUSSION
The operation presented is not a panacea for all breast deformities. Each surgeon has individual preferences for techniques and " tricks " evolved from a study of his own cases as well as those of others. We do contend, however, that generally superior results can be achieved by the use of this modification of the Biesenberger operation and that the main requirements of a satisfactory mammaplasty can be met in the majority of cases (Figs. 6, 7, and 8). Preservation of nipple function is important, particularly in patients of child-bearing age. Free nipple transplantation described by Thorek (I922, 1946) and popularised by Adams (1944, I947), Conway (I952), Marino (1952), and others has no advantage over transposition, and in many patients in whom it has been performed has been, we feel, physiologically unsound. Free nipple grafts may be m~l~a~,~' 4... . . . -~ m" extreme!y l. .~. r. g o hre~gts in late life as advocated by May. ;,,~e,'~,..~;~, and others : howeTer, even in gyn~ecomastia it has not been necessary in this series. This is ~ r t i c u l a r l y true in that the iargest breasts cu~,,J~tered wcrc in the younger/age group, and it seems unsurglcal to aestroy topple tun~t~u~J _.,_~z;,c;c patients ychere it can be so easily preserved. Ig/~he great majority of cases the desired result can be achieved in a one-stage proc.ddure, without the need of subjecting the patient to a second operation. / Marcus (I934), after an anatomical study of blood supply to the breast, concluded that the internal mammary and lateral thoracic arteries take the major part in circulation to t h e breast in about 5° per cent. of cases, and are equally responsible in 2o per cent. He believed nipple supply is by the lateral thoracic as well as the internal mammary in 63 per cent. and that the lateral thoracic is the main supply to the niplble in I3 per cent. We believe that preservation of the " mesentery" of the breast pedicle along the lower edge of the pectoralis major is extremely important if the blood supply of the breast tissue is to be assured. Ragnell (I946), after ninety-eight in a series of 3o0 cases, gave up the Biesenberger operation due to circulatory difficulties (cyanosis, nipple loss). In his later cases he preferred a double-pedicle method in two stages if necessary, The second stage consisted of a trim up. The incidence of the secondary operation was considerable.
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Aufricht (I949) believes the perforating vessels are also important. He and Barnes (I948! preserve the lateral and medial breast segments and resect the superior portions. Penn 0955) and Maliniac (I949), as well as Ragnell, prefer
FIGS. 6 and 7 Fig. 6.--Example of breast reduction m a typical Type II (broad, heavy, obese) case. Fig. 7 . - - A n example of the Type IV case, virginal hypertrophy, with reduction by the technique described in Figs. I to 5.
to leave the lateral and medial breast segments intact and resect the breast tissue accordingly. Penn prefers inferior wedge resections and a secondary operation for trimming. The writers believe that h~ematomata are most often at fault in post-operative circulatory disturbance. These may be very localised. The segment of breast resected is not the prime consideration, and lateral resections of mammary tissue can be done with security. There was no single case of mammary pedicle necrosis in this series.
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About Io per cent. of the cases in this series had a history of mastitis. Mastiffs is not a contraindication to surgery; indeed, it is a positive indication, and this type of operation should supplant amputation. These cases should have multiple
view was taken fourteen days after operation.
biopsies of involved areas. Mammaplasty does not reactivate mastitis and no case of cancer has,supervened. Total nipple ~oss, when it occurs, is probably best dealt with by a free graft of labia minora as described by Adams (1949). The technique of mammaplasty should be mastered by every young plastic surgeon. Demand for this operation is on the increase, and it promises to be an exceedingly common procedure in years to come. For a woman to go through life with over-sized weighty breasts is quite unnecessary. The larger the breast the more unlikely is it to be a satisfactory organ of lactation, while the damage done to the posture as well as to the ego can be serious and should not be taken lightly. SUMMARY I. A report of 347 consecutive cases of breast reduction is given as regards classification, type of operations, complications, and results. 2. A modification of the Biesenberger operation is presented in detail.
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3. H m m a t o m a is the m o s t serious c o m p l i c a t i o n a n d is p r o b a b l y responsible for m o s t o f the surgical disasters i n breast r e d u c t i o n . 4. C o n t r o l l e d h y p o t e n s i o n has i m p r o v e d t h e cosmetic result a n d r e d u c e d the t i m e o f operation. I t has also decreased t h e n u m b e r o f complications i n this t y p e o f surgery. REFERENCES ADAMS,W. M. (1944). Surgery, 15, 186. - - (1947). Sth. Surg., I3, 715. - - - - (1949). Plast. reconsrr. Surg., 4, 295. AUFRICHT,F. (1949). Plast. reconstr. Surg., 4, 13. BAMES,H. O. (1948). Plast. reconstr. Surg., 3, 560. BIESENBERGEg,H. (1935). Zbl. Chit., 62, 1218. CONWAY,H. (1952). Plast. reconstr. Surg,, io, 303. ENDERBY, G. E. H. (195o). Lancet, 1, 1145. Quoted by McIndoe. - - - - (1952). Ann. R. Coll. Surg. Engl., i i , 31o. GILLIES, H., and MCINDOE, A. H. (1939). Surg. Gynee. Obstet., 68, 658. MClNDOE, A. H. (195o). " Technique of Breast Reduction," in " Techniques in British Surgery," p. 264, ed. Maingot. London and Philadelphia : Saunders & Co. - - ( 1 9 5 6 ) . Plast. reconstr. Surg., 17, I. MALINIAC,J. W. (1949). Plast. reconstr. Surg., 4, 359. MARCUS, G. H. (1934). Arch. klin. Chit., I79, 361. MARINO, H. (1952). Plast. reconstr. Surg., IO, 204. MAY, H. (1956). Plast. reconstr. Surg., I7, 351. PENN, J. (1955). Brit. J. plast. Surg., 7, 357. RAGNELL,A. (1946). Acta chir. scand., Suppl. 24. THOREK, M. (1922). New York med. J., 116, 572. - - (1946). ~. int. Coll. Surg., 9, 194.
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during the operation. It has been found that a systolic blood-pressure of 80 to 90 ram. Hg is sufficient to limit the majority of operative bleeding without at the same time increasing the liability to post-operative hmmatoma formation. As will subsequently appear this is by far the most common post-operative complication. INDICATIONS FOR OPERATION
In the vast majority the main indication for operation is excessive weight of one or both breasts. Patients with heavy pendulous breasts are handicapped mentally and physically. In young women embarrassment increasing to genuine neurosis may seriously affect their adjustment to normal social life. Particularly is this so on the dance floor, in the swimming pool, or during those complicated emotional phases of womanhood which should lead to the wedding bells. In later years poor posture may lead to kyphosis or cervical arthritis (Conway, 1952) with chronic exhaustion and lassitude. Painful grooving of the shoulders from brassiere supports, together with unpleasant submammary intertrigo, produce a condition which few women wish to tolerate. Unilateral enlargement of one breast or atrophy of the other may determine operation. Finally, painful chronic mastitis, so often a feature of mammary hypertrophy, can be adequately treated by mammaplasty rather than the commordy advised but completely unjustifiable bilateral amputation. AGE INCIDENCE
The youngest patient in this series was 15, the oldest 62. Eight per cent. of the patients were in the second decade of life, 27 per cent. in the third, 27 per cent. in the fourth, 18 per cent. in the fifth, and 18 per cent. in the sixth. It is of interest that the largest amounts of tissue were resected in the young, particularly those with virginal hypertrophy or true gynmcomastia. TABLE I Types of Cases Type/.--Long, flabby breasts with or without glandular
35 hypertrophy (adolescent type) Type//.--Broad, heavy, obese breasts 2oi Type IIL--Pendulous, sac-like, following pregnancy 87 and/or obesity reduction Type IV.--Virginal hypertrophy (true gynmcomastia) I7 Type V.--Asymmetry (unilateral micromastia) 7 CLASSIFICATION
Table I represents a classification of the patients according to their physical characteristics (Mclndoe, I95O). Easily the largest number (2Ol) were Type II, broad heavy breasts unrelated to any other observable factors than obesity and glandular insufficiency. Operation was indicated because of excessive weight which limited social and physical activity. Eighty-seven were Type III following repeated pregnancies or weight reduction. Here the skin had been permanently stretched by glandular or fatty enlargement, indicated by linem striae, with descent of the breasts to the mid-abdomen or even lower. Disappearance of fat or atrophy
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of the glandular element leaves a loose pendulous sac often amounting to a positive deformity. Thirty-five were Type I. There is little difference between Type I and Type III except that the former occur in the young and in the absence of general obesity. Glandular imbalance is almost certainly the cause. Seventeen were Type IV (true gynmcomastia) and were often grotesque. Many of these patients had had extensive hormone therapy without the slightest benefit. The largest amounts of tissue were removed in this group, in one girl of I5 years 18 lb. from the two sides. Seven cases were Type V in which unilateral enlargement or micromastia was present. TABLE
II
Primary Operations Total number of cases, 3 4 7 Bilateral Unilateral General anaesthesia Controlled hypotension'
340 7 276 7I
Total number of complications, 39 General anaesthesia Controlled hypotension'
32 7
Glandular operation performed Lateral resection (Biesenberger) Bipedicle (Gillies-McIndoe) . Inferior wedge resection Free nipple transplant .
337 5 3 2
Skin excision performed Transverse ellipse (Passot) Inverted " T " (McIndoe)
IO 337
PRIMARY
OPERATIONS
Two general types of operation have been described. Firstly, those in which the nipple is transplanted freely to a reconstructed breast and in which function is entirely neglected, and secondly those in which the nipple is attached to a breast pedicle and function is preserved. Free nipple transplants were carried out in two cases only. The writers regard this method as cosmetically inferior and physiologically unsound and have abandoned it. It is possibly applicable to older women in states of extreme obesity but rarely, if ever, in the young or middle-aged. In the remaining 345 patients one or other of the pedicled methods was used. In a previous publication (Gillies and McIndoe, I939) a report was made on a bipedicled operation consisting of excision of the central superior portion of the gland and elevation of the remaining mammary tissue on medial and lateral pedicles. This method has been extensively utilised by Ragnell. As seen in Table II, five of these operations were performed and the method then abandoned because of uncertainty with the blood supply of the nipple and the frequency of secondary operations. Wedge resections were carried out in five cases where little elevation was required. This type of operation is more useful as a secondary procedure. The great majority of primary operations (337) were done by a modification of the original Biesenberger (1935) operation in one stage. The modification consists
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(a) in the formation of a medial glandular flap carrying the nipple at its apex with resection of the lateral and axillary elements : the blood supply is made entirely safe by preservation of a " m e s e n t e r y " along the inferior border of the pectoralis major containing branches of the lateral thoracic artery; (b) in the construction of a firmly fitting skin brassiere so attached inferiorly to the chest wall that the breast tissue cannot slip behind the transverse scar. This operation has given such satisfactory results that it will be presented in some detail (Figs. I to 5).
'/zto z in.
\
Ski n
FIG. I Operative technique. OPERATIVE TECHNIQUE
The patient is anmsthetised, intubated, and placed on the operating table in the classical semi-sitting position with the arms akimbo. Controlled hypotensive ana:sthesia is used at a pressure of 8o mm. Hg. After preparation of the skin the operative area is draped to give a good general view of both breasts in relation to the shoulders, the sternal notch and the xiphoid. It is important that the shoulders should be kept square so that the nipple positions can be accurately determined. The landmarks are measured with callipers and compass and checked repeatedly throughout the operation. Depending on the width of the shoulders, the size of the thoracic cage, and the age of the patient the nipples are situated
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7½ to 9{ in. from the sternal notch and 4~ to 6½ in. from the xiphoid. The intersection of the two circles described by the callipers settles the point roughly, but it is clear that the operator's judgment will have much to do with the final positioning. The inter-nipple distance should rarely be less than io to Ii in. /
FIG. 2 Operative technique.
and the nipples should eventually end at the apex of the breast cone pointing forwards and outwards (Fig. I, a). The nipples themselves are then tightly stretched peripherally by the assistant's hands while the areola is circumscribed with compasses. The diameter of the areola is about I½ in., but this, too, varies with the size of breast to be constructed. The skin is split for a distance of at least ~in. round the nipple, so that the periareolar plexus of nerves and vessels and the areolar smooth muscle fibres are preserved. This is an important step and upon the care with which it is carried out will depend the life and sensitivity of the nipple. The vertical skin incision is then carried down to the submammary groove
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and upwards to the presumptive position of the new nipple. The substance of the breast is then dissected away with large dissecting scissors from the medial and lateral skin flaps so formed. Denudation of the breast is extensive, particularly upwards where it should reach to the second rib. By this means a circular base / /
FIG. 3 Operative technique.
for the new cone of breast tissue is established which will be neither too large nor too small. It is rarely sufficient until the perforating branches of the thoracic axis are divided. Having thus denuded the entire breast substance, the~requisite amount of tissue is resected in an S-shaped fashion according to the Biesenberger technique with one important modification. Great care is taken to preserve the medial attachment of the breast pedicle along the lower edge of the pectoralis major. This so resembles a " m e s e n t e r y " that it has thus been designated (Fig. 3, i and j). It contains branches of the lateral thoracic artery not hitherto considered
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important. The writers believe that sacrifice of this considerable blood supply is a common cause of breast tissue necrosis. The freed portion of the breast pedicle is then rotated superiorly and lightly sutured with plain catgut to form a cone of breast tissue and fat. It is important that this approximation to complete the general shape be carried out without any vascular embarrassment (Fig. 3, k and l). A skin hook is then placed at the upper end of the vertical incision (where the new nipple will lie), and this is drawn strongly forwards. The breast cone is
J
FI~. 4 Operative technique.
pushed into the tent of skin so formed and the medial and lateral skin flaps are wrapped around its inferior surface and snugly held there by the application of a large, smooth, curved Doyen's intestinal clamp (Fig. 4, m and n). It is at this moment that the skin brassiere is correctly formed, and failure to judge it accurately will result in poor shape. The skin is manipulated through the clamp tintil the breast cone is tightly clothed with skin, after which the excess below the clamp is excised and the skin edges carefully sutured with fine silk (Fig. 4, o). The submammary excess of skin now lying transversely in the submammary groove is excised as economically as possible. To effect this it is removed by an oval cut,
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thus making the shortest transverse scar in the groove. These incisions on each side should end up identical in length and symmetrically placed (Fig. 5, s). They are anchored to the costal fascia by four heavy silk sutures which serve to secure the submammary transverse incisions to the chest wall and so prevent sagging of the breast tissue below this line. " Dishing " of the breast is one of the most
,
/. J
\\,
"'"'"
Apeo undermined FIG. 5 Operative technique.
common post-operative sequela: of this operation and can be easily controlled in this way. At this stage an appropriate circle of skin is marked ou{ for excision on the apex of the skin brassiere. This is done after careful rechecking of measurements both from the sternal notch and the xiphoid to ensure symmetry (Fig. 4, P). It is well at this stage for the operator to stand at the foot of the table and visually check the location of the nipples and the general shape of the breasts. If these are satisfactory the circular piece is excised, the nipple extruded and sutured into
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position with fine silk. The diameter of the areola when stretched should equal that of the skin excised from the apex. After this the remaining incisions are meticulously finished with fine silk and terminal excesses removed in the usual fashion. Soft rubber drains are inserted medially and laterally in the lower transverse incision to drain the superior and inferior spaces. The same procedure is carried out on the opposite side and a pressure dressing to be left on four days is applied. All sutures except the heavy tension sutures in the transverse incision are removed by stages beginning on the fifth post-operative day with the periareolar sutures. The heavy sutures remain in for ten to twelve days to ensure a firm fibrous attachment of the scar to the chest wall. COMPLICATIONS
Few papers dealing with this subject have dealt with complications, though Conway (I952) recently reported twenty-two in I Io cases of mammaplasty of all types. Ragnell has also reported his complications (Ragnell, i946). This paper presents all complications encountered, no matter how trivial. These are shown in Table III and are self-explanatory. They have been as far TABLE
III
Complications Number of Cases Operated. Complication.
General Anaesthesia.
Heematoma (bilateral) . Haematoma (unilateral) . . Total nipple loss due to h ~ e m a t o m a * Partial nipple loss due to h~ematoma Abscess-infected h~ematoma . Partial nipple loss (unilateral) without haematoma Partial nipple loss (bilateral) without hrematoma Marginal slough of skin flaps Partial wound separation without slough Diffuse local sepsis . . Local fat necrosis with sinus tract . Cerebral thrombosis or embolism . " Dry"
pleurisy
.
Percentage of total number of cases total
3 2
II I
4 I
2 I
I
3 5
I I
2 2 I I
Total
Percentage of operations
Total. Hypotensive.
nttmber
of
32
7
39
II.6
9'9
II'2
IO ' 5
8.9
io'2
* Nipple sloughs associated with small subareolar haematomas.
as possible accurately and independently assessed by the junior writer and accepted as such by the senior.
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The cases are divided into those operated under controlled hypotension and those done previous to 195o under general ana:sthesia. As seen from Table III, thirty-two cases or I 1.6 per cent. of the 276 cases operated on prior to controlled hypotension developed some sort of complication. Following the advent of hypotension in 195o , seventy-one cases have been operated, with seven complications (9"9 per cent. of cases and 8"9 per cent. of the total number of hypotensive operations). This is a significant lowering of the complication rate. Ha:matomata have particularly decreased. There has been only one case of minimal nipple slough since hypotension was adopted. Of all post-operative complications, ha:matoma has been the commonest. Massive ha:matoma is easily recognised and should be dealt with by immediate operation, complete evacuation of the clot, resuturing of the wound with drainage. The smaller localised ha:matoma, on the other hand, is less often recognised but can be the seat of serious trouble. We wish to emphasise one point brought out in this study. The single case of complete nipple slough and five of the seven cases of partial loss were associated with small, localised para-areolar ha:matomata. It appears, therefore, that post-operative circulatory difficulties of the nipple are rarely due to primary circulatory insufficiency; ha:matoma is most often responsible by compression of the circulatory tree. In the past, attention to this matter has been directed towards preserving nipple blood supply, giving rise to differences of opinion in the technique of gland resection. We feel that ha:matomata should be diligently searched for at the first appearance of nipple distress. If these are found, and evacuated early, undoubtedly some of these nipple disasters would be avoided. The remaining complications are listed and are largely self-explanatory. The case of hemiplegia occurred twelve hours after operation. Subsequent studies did not reveal an anomaly of the vascular tree to the brain, and it must be assumed that a cerebral embolism was responsible. The patient recovered with minor sequela:. The patient with fibrinous pleurisy was investigated and no a:tioiogy determined. She recovered. The fatality rate was nil. The term " f a t necrosis " is misleading. It usually occurs to some degree in the presence of ha:matoma or inflammation. It can occur alone, with or without a slough or sinus tract. It can prolong convalescence considerably due to the time taken for the sloughing fibrous tissue to separate. Small areas may be left to heal spontaneously, but if the slough is extensive prompt excision i s the best treatment. SECONDARY OPERATIONS
Table IV tabulates all secondary procedures, including those patients who had primary surgery elsewhere. These include immediate operations for complications and delayed reconstruction of defects secondary to complications-i.e., skin loss, nipple loss, etc. In addition, secondary revision of scars and remodelling are listed. It is again of significance to note the decreased number of secondary operations necessary since the advent of controlled hypotension. The ease of operating in a bloodless field permits more careful attention to detail before fatigue from a long operation blunts the senses of the operator.
MAMMAPLASTY
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TABLE IV Secondary Operations
Scar revision R e m o d e l l i n g (gland) Reposition nipples . Excision w o u n d slough Excision nipple slough . . . Excision of o p e n areas a n d resuture R e m o d e l l i n g of result operated elsewhere E v a c u a t i o n hzematoma . N i p p l e reconstruction w i t h free graft ( S - T i Total
Controlled Hypotension.
General Anaesthesia.
i
7
•"
4
,..
I
...
2
.,,
I
I
I
3 2
z 8
...
I
7
27
DISCUSSION
The operation presented is not a panacea for all breast deformities. Each surgeon has individual preferences for techniques and " tricks " evolved from a study of his own cases as well as those of others. We do contend, however, that generally superior results can be achieved by the use of this modification of the Biesenberger operation and that the main requirements of a satisfactory mammaplasty can be met in the majority of cases (Figs. 6, 7, and 8). Preservation of nipple function is important, particularly in patients of child-bearing age. Free nipple transplantation described by Thorek (I922, 1946) and popularised by Adams (1944, I947), Conway (I952), Marino (1952), and others has no advantage over transposition, and in many patients in whom it has been performed has been, we feel, physiologically unsound. Free nipple grafts may be m~l~a~,~' 4... . . . -~ m" extreme!y l. .~. r. g o hre~gts in late life as advocated by May. ;,,~e,'~,..~;~, and others : howeTer, even in gyn~ecomastia it has not been necessary in this series. This is ~ r t i c u l a r l y true in that the iargest breasts cu~,,J~tered wcrc in the younger/age group, and it seems unsurglcal to aestroy topple tun~t~u~J _.,_~z;,c;c patients ychere it can be so easily preserved. Ig/~he great majority of cases the desired result can be achieved in a one-stage proc.ddure, without the need of subjecting the patient to a second operation. / Marcus (I934), after an anatomical study of blood supply to the breast, concluded that the internal mammary and lateral thoracic arteries take the major part in circulation to t h e breast in about 5° per cent. of cases, and are equally responsible in 2o per cent. He believed nipple supply is by the lateral thoracic as well as the internal mammary in 63 per cent. and that the lateral thoracic is the main supply to the niplble in I3 per cent. We believe that preservation of the " mesentery" of the breast pedicle along the lower edge of the pectoralis major is extremely important if the blood supply of the breast tissue is to be assured. Ragnell (I946), after ninety-eight in a series of 3o0 cases, gave up the Biesenberger operation due to circulatory difficulties (cyanosis, nipple loss). In his later cases he preferred a double-pedicle method in two stages if necessary, The second stage consisted of a trim up. The incidence of the secondary operation was considerable.
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Aufricht (I949) believes the perforating vessels are also important. He and Barnes (I948! preserve the lateral and medial breast segments and resect the superior portions. Penn 0955) and Maliniac (I949), as well as Ragnell, prefer
FIGS. 6 and 7 Fig. 6.--Example of breast reduction m a typical Type II (broad, heavy, obese) case. Fig. 7 . - - A n example of the Type IV case, virginal hypertrophy, with reduction by the technique described in Figs. I to 5.
to leave the lateral and medial breast segments intact and resect the breast tissue accordingly. Penn prefers inferior wedge resections and a secondary operation for trimming. The writers believe that h~ematomata are most often at fault in post-operative circulatory disturbance. These may be very localised. The segment of breast resected is not the prime consideration, and lateral resections of mammary tissue can be done with security. There was no single case of mammary pedicle necrosis in this series.
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About Io per cent. of the cases in this series had a history of mastitis. Mastiffs is not a contraindication to surgery; indeed, it is a positive indication, and this type of operation should supplant amputation. These cases should have multiple
view was taken fourteen days after operation.
biopsies of involved areas. Mammaplasty does not reactivate mastitis and no case of cancer has,supervened. Total nipple ~oss, when it occurs, is probably best dealt with by a free graft of labia minora as described by Adams (1949). The technique of mammaplasty should be mastered by every young plastic surgeon. Demand for this operation is on the increase, and it promises to be an exceedingly common procedure in years to come. For a woman to go through life with over-sized weighty breasts is quite unnecessary. The larger the breast the more unlikely is it to be a satisfactory organ of lactation, while the damage done to the posture as well as to the ego can be serious and should not be taken lightly. SUMMARY I. A report of 347 consecutive cases of breast reduction is given as regards classification, type of operations, complications, and results. 2. A modification of the Biesenberger operation is presented in detail.
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3. H m m a t o m a is the m o s t serious c o m p l i c a t i o n a n d is p r o b a b l y responsible for m o s t o f the surgical disasters i n breast r e d u c t i o n . 4. C o n t r o l l e d h y p o t e n s i o n has i m p r o v e d t h e cosmetic result a n d r e d u c e d the t i m e o f operation. I t has also decreased t h e n u m b e r o f complications i n this t y p e o f surgery. REFERENCES ADAMS,W. M. (1944). Surgery, 15, 186. - - (1947). Sth. Surg., I3, 715. - - - - (1949). Plast. reconsrr. Surg., 4, 295. AUFRICHT,F. (1949). Plast. reconstr. Surg., 4, 13. BAMES,H. O. (1948). Plast. reconstr. Surg., 3, 560. BIESENBERGEg,H. (1935). Zbl. Chit., 62, 1218. CONWAY,H. (1952). Plast. reconstr. Surg,, io, 303. ENDERBY, G. E. H. (195o). Lancet, 1, 1145. Quoted by McIndoe. - - - - (1952). Ann. R. Coll. Surg. Engl., i i , 31o. GILLIES, H., and MCINDOE, A. H. (1939). Surg. Gynee. Obstet., 68, 658. MClNDOE, A. H. (195o). " Technique of Breast Reduction," in " Techniques in British Surgery," p. 264, ed. Maingot. London and Philadelphia : Saunders & Co. - - ( 1 9 5 6 ) . Plast. reconstr. Surg., 17, I. MALINIAC,J. W. (1949). Plast. reconstr. Surg., 4, 359. MARCUS, G. H. (1934). Arch. klin. Chit., I79, 361. MARINO, H. (1952). Plast. reconstr. Surg., IO, 204. MAY, H. (1956). Plast. reconstr. Surg., I7, 351. PENN, J. (1955). Brit. J. plast. Surg., 7, 357. RAGNELL,A. (1946). Acta chir. scand., Suppl. 24. THOREK, M. (1922). New York med. J., 116, 572. - - (1946). ~. int. Coll. Surg., 9, 194.