A Step-by-Step Approach to a Successful Cosmetic Breast Reduction (PRS)

Introduction

Breast reduction aims to remove excess tissue, relocate the nipple, and create a pleasing shape while minimizing scarring & maintain sensation. The most common technique used is the inverted-T, inferior pedicle design with Wise pattern skin markings, but other techniques have emerged.  

Adequate pre-operative markings and intraoperative strategies can simplify the procedure and achieve satisfactory results with a step-by-step approach described in this article.

Step-by-Step Approach

Step 1: Symmetrical Preoperative Markings

• Mark the midline and inframammary fold.
• Medial markings must be symmetrical between both breasts. For highly asymmetric breasts, lateral markings may differ.
• Estimate the centre of the new nipple position by tracing a horizontal line 1cm over the inframammary fold and marking the breast mound at the level of the breast meridian.
• The superior border of the areola should be marked approximately 2cm above this marking, and the standard diameter for the areola is 4cm.

Step 2: Early Design of Pillars

• Before parenchymal excision, define the medial and lateral pillars by tracing 7cm vertical lines on each side from the lower limit of the new areolar opening.
• Keep the medial pillar full thickness for improved fullness and projection, and thin the lateral pillar to around 2cm.
• Excise tissue at the inferior and lateral areas along the mastectomy cleavage plane, leaving a 4-5mm adipocutaneous flap.

Step 3: Key Untied Stay Sutures

• Placed two untied nylon 3-0 stay sutures between the new areolar opening and the areola (12 o’clock, and 6 o’clock) after parenchymal excision and secured with 2 Kelly forceps.
• The stay sutures provide a 3-dimensional perspective of the new breast by pulling towards the zenith, aiding in size estimation between both breasts, and helping during pillars closure.

Step 4: Restoring Lateral Breast Contour

• A curvilinear piece of glandular tissue is excised from the caudal part of lateral pillar, leaving a thin dermal flap. This is to restore the natural lateral breast contour.
• The location and extent of excision is determine by outlining the ideal lateral breast curvature on the skin.
• Consider adding liposuction to the lateral breast in large reductions to avoid extended horizontal scars and improve shape at the end of the procedure.

Step 5: Pedicle Suspension

• Rotate or displace the pedicle superiorly without tension.
• Fix the pedicle to the pectoralis fascia using 2-3 nonabsorbable sutures in the superior limit of the upper pole dissection.
• Keep the cephalic dissection limit around the most superior extent of the breast footprint.

Step 6: NAC Fixation before Pillars Closure

• Suture the NAC to the new areolar opening before closing the pillars.
• This reduces tension during closure and prevents undesired downward traction of the nipple.
• It also helps to avoid abnormal protrusion of the areola after breast assembly.

Step 7: Pillars Closure with Hanging Breast

• Keep traction of the breast mound toward the zenith with an assistant.
• Close pillars using 2 layers of nonabsorbable sutures.
• Hanging the breast during closure exposes the correct alignment of the pillars and often results in increased projection and better shape.

Step 8: Intersection Suture

• Place a stay suture at the intersection between the meridian and both medial and lateral flaps.
• The suture assists with tailoring of skin excess
• Keep the suture in place until breast closure is completed.

Step 9: Horizontal Skin Excision

• Horizontal skin excess is removed at the end of the procedure, reducing final scar length.
• Redundant skin is incised at the superior border, forming two inferiorly based skin flaps.
• With assistant pushing the breast caudally, use the the natural crease of the IMF as a guide for determining the amount of skin excision needed.

Article Discussion

3 Learning Points

• Importance of keeping medial marking symmetrical.
• Use of stay sutures around NAC to improve size estimation.
• Lateral breast contouring

3 Discussion Points: Positives, Limitations

• Nice stepwise approach for cosmetic breast reduction using a mosque dome skin marking and a superomedial pedicle.
• This is limited to small to moderate sized reduction – might be less applicable in the UK.
• Excellent video on marking the breast.

3 Ways to change your practice.

• Precise marking is essential.
• Pedicle suspension
• Lateral breast contouring

3 Recommended Reads

1. Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg. 2015;136:531e–544e.
2. Andrades P, Prado A. Understanding modern breast reduction techniques with a simplified approach. J Plast Reconstr Aesthet Surg. 2008;61:1284–1293.
3. Davison SP, Mesbahi AN, Ducic I, et al. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg. 2007;120:1466–1476.