2.7 Breast Reduction, Edward p. Melmed
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1518 S .A . MED ICAL JOUR 'AL 14 October 1972
were found to be the cause of the uterine inertia . The
in fan t was v ital and showed no pathological signs. The
labour occurred on the 264th day of pregnancy. Accordingto my observations, the average durat ion of pregnanciesafter successful artificial insemination is 265 days.
REFERE 'CES
I. Jobansson, C. J. (1957): Acta obs te t. g ynec . s cand ., 34, suppl. 5.2. Sill6-Seidl, G. (1967): Die Uncersuchung und Behandl llng des k inder-
losen Ehepaares. Munich: Lehmanns Verlag.3. Idem (1969): Med. Gynaec ., 4, 239.4. Idem (1967): Anti. Praxis, 19. 2947.5. Idem (1971): J. Obs tet . Gynaec. Ind,a, 2 1. 486.
Breast Reduction *
EDWARD P. MELMED, t M.B. B.CH. 'IV. RAND, F.R.C.S. liNG., F.R.C.S. GLASG., Senior Specialist and Part-timeLecturer, Department of Plastic Surgery, Groote Schuur Hospital, Observatory, Cape
SUMMARY
A review of 32 cases of breast reduction fo r macro-
mastia is presented, and the resul ts of using the Strom-
beck and Skoog techniques discussed.
S. Air. Med. J., 46, 1518 (1972).
Early attempts at reduction of the hypertrophied breast
were confined to partial amputation' suspension opera
tions'" and sk in resection.'" Beisenberger' described atechnique based on rotat ion of a single glandular pedicle,with nipple transfer, and this r emain ed the most popul ar
technique un til the early 196Os.8,9 However, this method
had problems with the vascu la r supply and frequently
the breas ts sagged after a few years:
Plastic operations fo r the correction of pendulous and
hypertrophied breas ts fa ll into 2 main categor ies: onewhere the nipple is transferred on a vascular pedicle, and
the other in which it is transferred as a free graft. The
latter method is now seldom used, and is mainly reservedfor huge breasts.' ·
Transposition of the nipple may be achieved by skin in
cisions around the nipple and division of the cutaneous
blood supply, the nipple vascularity coming fr om theunderlying glandular t issue alone.n .l' There may be a
single"" or a double glandular pedicle."''''Preservation of the cutaneous glandular vascular pedicle
communication to the nipple and rotation of the nipplebased on this flap, were introduced by Schwartzmann."
The S trombeck technique" is based on this glandular
cutaneous pedicle, bu t utilizes a double pedicle. The
Strombeck technique is very popular, bu t ip about a thirdof t he cases the nipples are inverted9 and the bottom of
'Date received: 17 ADT il 1972.tPresenr address: 5'15 Medipark, F or es ho re , C ap e T ow n.
the breas t is flat. Suspens ion procedures with dermis or
fascia have no t proved effective in preventing this. '"
Skoog lO descr ibed a technique in which transposition isbased on the pedicle cutaneous vessels only. This singleapron is based on a skin-f lap with the blood supply to the
nipple coming from th e subcutaneous dermal plexus.
CLINICAL EXPERIENCE (Table I )
Indications for Operation
All patients who requested breast reduction complained
of disproportionate size. Nineteen patients complained of
the weight of the breasts, 7 of pain in the back and
shoulders, and 9 of poor posture. Most patients (21)showed a strong reluctance to wear a swimming-costume,due to embarrassment. Most s ta ted that they had to buyspecial brassieres. Similarly, clothing had to be speciallytailored to fit the outsize bust-line. Each symptom may beregarded alone or in combination with disproportionate
size, as an indication for operation.
The patients mental attitude needed consideration.
Overweight patients were not accepted fo r operation untiltheir body-weight fell to acceptable l imits for height and
build.
CLINICAL MATERIAL
Thirty-two patients were operated on; 17 pairs of breasts
were reduced by using the Strombeck technique, and 14 bythe Skoog technique. One patient had gigantism, and had
been previously operated on in Portugal (Fig. la ). She wasreduced by the Pitanguay technique (Fig. lb).
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14 Oktober 1972 S . -A . MED I E SE TYDSKR I F
TABLE I. CLINICAL EXPERIENCE WITH 32 CASES OF BREAST REDUCTION
\
]519
Patient
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Age
46
18
23
21
20
18
21
23
50
20
1552
52
18
45
58
54
29
25
26
24
28
19
42
39
21
27
21
28
16
24
25
Size
+
++++++
+
+
+
++++
+++
+
+
++
++
+
+
+++
Symptoms
Poor
Weight posture
+ ++ +
++ ++ +
+
+
+
++ +
+
+
+ +
++
+ +
+
+
+
++
+
Pain in
back
+
+
+
+
+
+
Social
embar
rassment
+++
++
+
+
+++
++
++
++
+
++
+++
+..L-++
Operation
Strom-
beck Skoog
+
++
++
++
+
+
+Pitanguay+
+++
+
+
++
++
+
++
++++
++
Weight
removed
NS*
NS
NS
340 g/34O 9
NS
766 g/766 9
850 g/850 9
NS
1 6 00 g/1 600 9
NS
NSNS
NS
570 g/570 9
510 g/624 9
NS
NS
454 g/454 9
227 g/227 9
480 g/570 9
227 g/280 9
680 g/710 9
NS
NS
NS
NS
NS
227 g/200 9
200 g/200 9
850 g/794 9
280 g/340 9
710 g/74O 9
Comments
Good result. Pendulous
breasts . Long pedic lesGood resul t
Good resul t
Good resul t
Good resul t
Very good (Fig. 8)
Good. No t sufficient
breast t issue removed
Poor result - flat breast
w ith inver ted n ipples
Exceptionally big breasts.
Pedicles 34 cm. Good
result
Good result
Fig. 1 (see text)Poor result. Inverted
nipples
Sat is factory. Breas ts f la t
Very good. (Fig. 7)
Very poor. Nipple necro
sis on left side·
Good resul t. Long
pedicles
Good result. Combined
w ith abdominal lipec
tomy
Very good. (Fig. 6)
Satisfactory. Breasts flap.
Nipple inversion
Good resul t
Good. Breasts slightly
flat
Good result. Pedicle 6
cm
Breasts flat
Poor resul t. F la t breas ts .
Nipple inversion (Fig.
5)
Good resul t
Fair result
Flat bottom to breasts
Breasts flat
Good result
Good resul t (Fig. 3)
Good resul t
Good result
• NS = no t stated.
Principles of Procedures Used
Strombeck technique:" This technique is based on the
main vascu la r supply to the breast, coming from the
branches of t he in ternal mammary artery, and from
branches of the axillary artery. A wedge-shaped resect ion
11
of glandular tissue is made above and below the areola,
leaving 2 vascular-glandular pedic1es (Fig. 2). Breast tissueis excised above and below the nipple without under
mining the skin.
Skoog technique:' · The operation is imilar to the
Strombeck technique. bu t relies on the cutaneou s ve sels
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1520 S.A. MEDICAL JOURNAL 14 October 1972
Fig. la . Patient 11, aged 15 years, with gigantism who was re fe rred to us f rom Luanda. She had been given'hormones' t o p romo te brea st growth at the age of 10 year s, and breas t r educ tion had been attempted inPortugal when patient was aged 14 years.
. t < l J ~ :.
."
Fig. 2. Strombeck technique. (By courtesy of StrOmbeck,J. O. (1970): Plastic Surgery. Boston: Little, Brown).
d
tJ'c - ~ - -e ' c . ,
~ I _ :" "'. . .~ . ~ ; : ~ ..
Fig. lb. Patient 11, reduced by a modif icat ion of the
Pitanguay technique.
alone for vascularity of the nipple (Fig. 3).In both techniques, pre-operative markings are made as
described by Wise" (Fig. 3). A point is marked 19 - 22 cm
(depending on the patient's size) along a line from theupper sternal notch to the nipple. This'- represents theupper a reolar border . The remaining skin markings are as
illustrated. Skin marking must always be made with the
patient sitting or standing.
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14 Oktober 1972 S . -A . M E DIE SE T YD SK R IF 1521
Fig. 3. Skoog techn ique . Skin markings showing singledermal apron flap (shaded area) which will carry nipple.
Fig. 4. Operation in progress. Right breast completed.Note markings.
Clinical Groups
The ages o f th e patien ts varied between 15 - 58 years.The patients fell into 2 distinct age groups; those aged16 - 28 years (26 cases) and an older group aged 40 - 58years (8 cases). This latter group had felt self-conscious alltheir adult lives, but had taken a long time to have the
procedure done.
RESULTS
Stay in Hospital
Postoperatively, there was no difference between the
techniques. The s tay in hospita l vari ed from 6 to 14 dayswith an average of 8 days. One patient with complicationsstayed 21 days.
Tissue Removed
The amount of breast tissue removed varied from 200 gto 900 g on each side. The average was 500 g. These
']
figures do not include the patient with gigantism, nor 1patient of 50 who had exceptionally huge breasts and
f rom whom 1600 g was removed from each side.All tissue removed was sent for histological section. '0
carcinoma was found in any of the specimens.
Wound Healing
The healing of all vertical and submammary incisionswas uneventful. Dehiscence of the peri-areolar suturesoccurred in only 1 case, and the patient suffered nipplenecrosis.
Vascularity
One patient suffered necrosis of the left nipple followingreduction by the Skoog technique. This was successfullytreated by free grafting from the labia minora." There
were no major problems of vascularity with the Strombeck
technique, though 1 patient had very severe blistering of
the nipple and areola. This recovered after 4 weeks, with
ou t skin loss.
Lactation
Patients were warned pre-operatively that no lactationwould be possible, due to division of the duct systems.This did not prove to be a deterrent and no one refusedto have the operation on these grounds. None of thepatients in the younger age g roup had fallen pregnant at
the t ime of writing.
Nipple Sensation
With both procedures, there is an immedia te total lossof sensation; sensation returned to normal in 50% o f both
series, and was acceptable , though decreased, in another
25% after 6 months.
Fig. S. Patient 24, aged 42 years. Flatness of t he b reas t
with nipple inversion after reduction by Strombeck technique.
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1522 S . A . MEDICAL JOURNAL 14 October 1972
Cosmetic Result
Mild flatness of the b ot to m o f the breas t was present in
most a ft er t he Strombeck procedure, an d was marked in
6 cases (Fig. 5). Fla tnes s was no t a featu re of th e Skoogprocedure, an d was present to a mild degree in 2 cases.Breast shape is better following the Skoog procedure
(Figs. 6, 7, an d 8). Unless the s ha ve d d er ma l pedicles of
Fig . 6. Patient 18, aged 29 years, before a nd a ft er reduction b y Sk oo g technique. About 450 g w as r e mo ve d from eachbreast.
Fig. 7. Patient 14, aged 18 years, before an d after reduction by ~ o o g technique. About 570 g was removed from,each breast.
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14 Oktober 1972 S . -A . M E DIE SE T YD SK R IF 1523
Fig. 8. Pat ient 6 , aged 18 years, before and after reduc tion by Skoog 'echnique . About 766 g was removed f rom each
breast.
the Strombeck procedure were long, inversion of the
nipple fol lowed (Fig. 4).
Patients' Subjective Views
All patients were delighted with the end result, includingthe pat ient who suffered nipple loss and who requi red
grafting. There can be few surgical procedures whichgive such satisfaction.
DISCUSSION
The Skoog technique appears t o have an advantage overthe Strombeck technique, by giving a better cosmetic
result.I f
the dermal pedicles of the Strombeck procedureare short , there is a high risk of inversion of the nipple.We prefer not to use the Strombeck technique unless these
loops exceed 5 cm. Secondary procedures to cor rec t inversion are not very successful. The Strombeck double
pedicle gives a safe blood supply to the nipple. In 1 case,each pedic le was 34 cm. However, when these pedicles areshort they run the risk of being twisted. One case sufferednecrosis of the nipple by the Skoog technique. In all othercases, blood supply from the single apron was adequate.
There is less rotation of the pedicle with t he Skoog tech-
13
nique. In selected cases for breast reduction, either
technique gives good results, and highly satisfied patients.
I wish to thank Or J. G. Burger, Superintendent of GrooteSchuur Hospi ta l, for permission to publish; and the followingdoctors fo r permission to use photographs of their casesoperated on at Groote Schuur Hospital: Dr J. A. Engelbrechtfor Fig . 4, and Or Oavid Davies for Fig. 5.
REFERENCES
I. MoreSlin, H. (1907): Bul l. Mem. Soc . Aviv. (Paris), 35, 996.2. Dehne r, A . (1908): Munch . med . Ws chr ., SS, 1878.3. Dar li qu es , M . (1925): Arch. franco-beIges Chir., 28, 313.4. LOlSCh, F. (1923): Zbl. Chir., 50, 1241.5. Noel, S. a nd L op es -Mar hn ez , M . (1928): Arch. franco-beIges Chir.,
31, 138.6. Gli isme r, E . (1930): Zbl . Gyniik. , 54, 2202.7. Beisenberger, H. (1931): Dejormitiicen und kosmecische Operacionen
der weibl ichen Brus!. Vien na : W. Mau dr ic h.8. McIndoe, A. (1950): Tech"iques ill British Surgery, p. 264. London:
W. B. Saunders.
9. Gupla, S. G. (1965): Bril. J. Plasl. Surg., 18, 328.10. Skoog, T. (1963): ACla. chi r. scand. , 126, 1453.
11. Passol, R. (1925): Presse med., 33, 317.12. C laoue, C . and Berna rd , I. (1936): Plastique Mammaire. p. 127. Paris:Libraire Maloine.
13. ~ a u r ~ ~ ~ ~ ~ s ~ e ~ ~ . L. (1939): Chirurgie Repartrjce et Correctrice. p. 372.
14. Barnes, H. O. (1948): Plasl. Reconstr. Surg., 3, 560.15. Auf ri ch l, G . (1949): Ibid., 4, 13.16. Arie, G. ( 1957 ): Rev . Ial.-amer. Cirug. plast., 3, 23.17. Penn, J . (1955): Bri l . J. Plast. Sur g. , 7 , 357.18. GilIies , H. and M cI ndoe, A. (1939): Surg. Gynec. ObSl el ., 68, 658.19. RagneU, A. (1946): ACla. chir. scand., 94, suppl. p. 113.20. Maliniac, J. W. (1948): PIasl. Reconslr. Surg., 3, 37.21. Schwartzmann, E. (1930): Chirurg., 2, 932.22. SlIombeck, J. O. (1960): Bril. J. Plasl. Surg., 13, 79.23. Idem (1964): Modem Tretuls i n Pl ast ic Surgery, p. 264. london:
Butterwonhs.24. Wi se, R. J. (1956): Plasl. Reconslr. Surg., 17, 367.25. Davies, D. (1971): Personal communication.