Discussion: Principles of Breast Re-Reduction
Breast re-reduction is a procedure that is best approached with caution. As a result of the previous procedure, the normal patterns of vascularity to the breast, skin, and nipple-areola complex are altered and aggressive approaches to perform re-reduction of the breast using what are otherwise standard and predictable techniques can produce ischemia, delayed wound healing, and possible necrosis in these tissues. In fact, it is not uncommon for these types of cases to have adverse medicolegal consequences. With this in mind, this well-written article by Hall-Findlay et al. highlights some of the important technical approaches that can be used to safely perform breast re-reduction in a predictable and safe fashion. Using a retrospective review of 90 patients who presented for breast re-reduction over a 23-year period, with each patient having a minimum follow-up of 6 months, the results obtained in this challenging group of patients are presented as reinforcement of the principles put forth by the senior author. These principles are as follows: (1) avoid the recreation of the old, or the creation of a new, pedicle to manage the blood supply to the nipple-areola complex and instead rely on random pattern revascularization to maintain the viability of the nipple-areola complex; (2) correct the inferior glandular ptosis that is invariably present by applying standard vertical technique removing a central wedge of tissue; (3) use suction-assisted lipectomy as an adjunct to reduce volume but in particular to remove tissue along the inframammary fold such that the fold is allowed to rise as the weight of the breast is removed; and (4) do not remove skin from the lower pole of the breast, as this skin is required to resurface a new breast mound. If the skin has stretched in the lower pole, it is removed only from the inframammary fold and up, as much as is needed, to redrape around the newly constructed lower pole contour. Applying these principles allowed these patients to safely undergo re-reduction with only a 2 percent incidence of minor necrosis of an areolar edge.
Taking these results into account, certain aspects of the topic of breast re-reduction merit specific comment. The average interval between breast reduction and re-reduction in this patient cohort was 12 years. This is in keeping with my own experience. It is uncommon for a patient to present early with a complaint of not being reduced enough; however, over time, life changes associated with age, change in weight, or pregnancy can result in recurrence of mild to moderate macromastia. During this interval, revascularization from the surrounding tissues makes reliance on the original pedicle much less important, and if this secondary revascularization is respected, moderate amounts of tissue can be resected, even from areas involving the original pedicle without risking embarrassment of the blood supply to the nipple-areola complex. The most common scenario that demonstrates this relationship, as noted by the authors, is the removal of an inferior central wedge from the inferior pole of the breast in a patient who has previously undergone an inferior pedicle inverted-T breast reduction. Here it must be stressed that wide undermining with the creation of new pedicles does put at risk the secondary sources of revascularization to the nipple-areola complex, and such surgical dissection is best avoided to ensure the safety of the procedure. To protect the secondary revascularization of the nipple-areola complex, it is highly recommended to use deepithelialization only when incorporating a lift to the position of the nipple-areola complex as part of the operative plan.