M. S. Kaminer, MDa,c,d, M.-H. Tan, MDa, T.-S. Hsu, MDa, M. Alam, MDa,b
aSkin Care Physicians, Chestnut Hill, MA, USA
bSection of Cutaneous and Aesthetic Surgery, Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
cDepartment of Medicine (Dermatology), Dartmouth Medical School, Hanover, MA, USA
dSection of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
Traditionally, dermatologic surgeons have referred women seeking breast reduction to plastic surgeons for excisional mammoplasty. However, with recent advances in small cannula tumescent liposuction surgery, referral for such surgery may be unnecessary in some cases. Breast liposuction can reduce the size of female breasts that have essentially normal architecture with a minimum of visible scarring and an aesthetically pleasing result. We describe a method for liposuction reduction of female breasts that is safe, efficacious, and associated with high levels of patient satisfaction. Liposuction for breast reduction in women is an appropriate addition to the array of liposuction procedures available to the dermatologic surgeon.
liposuction, breast reduction
A Brief History of Liposuction
Liposuction is the aesthetic removal of undesirable localized collections of subcutaneous adipose tissue. The procedure was developed in the mid-1970’s by Georgio and Arpard Fischer and advanced with innovative suctioning equipment created by Yves-Gerard Illouz. The technique of tumescent anesthesia introduced by Jeffrey Klein in 1987, significantly improved safety while reducing the complications associated with the procedure. Refinement of liposuction methods has enabled physicians to treat challenging areas such as arms, inner thighs, neck and jowls and more recently the female breast.
Breast Reduction Strategies
Breast reduction by liposuction includes several approaches. Traditional breast reduction surgery may be preceded or followed by moderate volume liposuction. Adjunctive use of liposuction can be useful for thinning pedicles, removing axillary and lateral chest wall fat, contouring the inframammary fold, and adjusting volume to correct asymmetries after conventional bilateral reduction mammoplasty. Alternatively, modest breast hypertrophies can be initially treated by liposuction, with the extent of further excisional mammoplasty dictated by the quantity of residual tissue. This approach is also used to treat congenital asymmetry in adolescents and to correct pseudoptosis. During the last decade, liposuction alone has been used for reducing mild gynecomastia that entails excess breast fatty tissue but near-normal glandular breast tissue. In 1991, Alan Matarasso and Eugene Courtiss1,2 reported that liposuction alone could reduce each treated breast by 75-475cc in patients aged 18 to 60. One to five-year follow-up found no fat reaccumulation or breast reenlargement.
Advantages of Breast Reduction by Liposuction
Breast liposuction can give dramatic results and offer significant advantages over surgical reduction. Unlike traditional approaches, breast liposuction does not require glandular resection and movement of the nippleareola complex on a local pedicle. Thus, the inverted Tshaped scar is avoided, and scars after lipectomy are virtually undetectable if the inframammary/axillary line approach is used. Since there is no cutting of breast tissue, more vessels, nerves, parenchyma and supporting connective tissue are left intact so there is minimal disturbance to sensation and lactation. From the standpoint of the surgeon, no pedicle, flap or dissection is required, and no parenchymal structures are transected. There is a consequent dramatic decrease in reported complications with liposuction alone compared to excisional breast reduction, which can in as many as 50- 60% of patients induce infection, bleeding, hematoma, seroma, wound dehiscence, skin necrosis, hypertrophic scars or keloids, poor breast shape, loss or alteration of sensation, or inability to breast-feed. Since liposuction is a minimally invasive outpatient procedure performed under local anesthesia, postoperative wound care is minimal and recovery time is brief. Maintenance of the architecture of the breast, including neurologic, vascular, and glandular structures, results in preservation of sensation and symmetry.
Is Breast Liposuction Safe?
Critics of liposuction for breast reduction have raised the possibility of interference with mammography.3 Potential problems after liposuction have been proposed to include septal distortion from scarring, increased breast density due to selective extraction of fat, and extensive fat necrosis culminating in microcalcification. While post-liposuction mammograms demonstrate greater tissue density and an increase of parenchymal microcalcification, these postliposuction calcifications are easily and reliably distinguished from malignant calcifications, which are less scattered, less regular, and more numerous.3,4 To further protect the patient, before liposuction, a preoperative mammogram should be obtained. Within six months postoperatively, a repeat study should be done to detect changes due to liposuction alone.
Who Should Get Breast Liposuction?
Certain criteria must be met for successful breast liposuction:1,2
- The patient’s skin tone must be sufficiently elastic for shrinkage to the post-operative contour. Patients with so-called “soft (non-elastic) skin” should be advised that they may be less than ideal candidates for breast reduction with liposuction alone.
- The nipple-areola complex must be well-located and the relationship of the nipple to the inframammary crease satisfactory. Satisfactory nipple position is an anterior orientation that is not inferiorly deviated or ptotic. Liposuction alone cannot correct nipple ptosis, reduce the size of the nipple-areola complex, or relocate the complex. Women with mild breast ptosis may experience mild to moderate post-operative improvement in ptosis. However, the definitive treatment for ptosis remains cold steel breast reduction surgery.
- The density of the breast must be appropriate. Treatable breast enlargement must be largely due to fatty tissue rather than excess glandular parenchyma, which is less amenable to liposuction.
Breast liposuction can provide a diminution of breast size of one to two cup sizes. Patients desirous of greater reduction should be counseled to consider excisional mammoplasty. Before breast liposuction, patients should receive a baseline mammogram. Anticoagulants and antiplatelet agents, such as vitamin E supplements and daily aspirin, should be discontinued a week in advance of the procedure in consultation with the patient’s primary care physician.
How is Breast Liposuction Performed?
Preoperative measurement of breast weight utilizing a digital scale and volumetric measurement using water displacement can help the surgeon decide how much fat to remove and how the total should be distributed between the two breasts to ensure an even result. Multiple, usually two, stab incisions are made in the inframammary crease of each breast with a third incision placed in the anterior axillary line. Tumescent anesthesia is then infused per customary technique.5-6 Infusion is performed throughout the entire breast as well as parallel to the plane of the chest wall. Approximately 600-800cc of tumescent solution is typically required to fill each breast and ensure that the deep portion of the breast adjacent to the chest wall is completely infiltrated. Thirty to forty-five minutes after tumescent infusion is complete, liposuction is initiated with appropriate cannulas, such as the 12-gauge Klein and 12- gauge Capistrano cannulas. Machine suction is performed via standard criss-cross triangulating technique, with fanning from each of the entry sites. Like tumescent fluid infusion, suction is best performed throughout the entire volume of the breast. It is essential that the surgeon continuously palpate and monitor breast size and symmetry during breast liposuction. The non-dominant hand is used to pinch and assess breast volume and contour as liposuction progresses. Superficial suctioning should be avoided, as should aggressive suctioning under the nipple complex. This process of conservatism and continual reevaluation increases the likelihood that breast symmetry and contour is maintained postoperatively. Additionally, many women benefit significantly from thorough, even fat removal from the lower outer quadrant of the breast. Treatment of this area can aid in volume reduction as well as skin retraction and mild breast elevation.
Results and Aftercare
Suction volumes vary, with 250-500cc of fat typically removed from each breast. At the conclusion of suctioning, the surgeon can readily confirm breast size and symmetry by palpating the breast to estimate the residual volume, as well as by comparing volumes of fat removed from each breast during the procedure. Use of a compression binder or support bra after surgery is essential. Continuous use of such a device for the first three months after surgery ensures maximum smoothness and uniformity of the final contour. The initial postoperative compression garment is worn 23 hours/day for the first 7 days, followed by the use of a properly fitted support bra 16-24 hours a day for the next 3 months. More so than with liposuction of other anatomic areas, the cosmetic end result is highly dependent on patient adherence to a strict regimen of garment use, and patients should be apprised of their vital role in this process.
Liposuction for breast reduction in women is an appropriate addition to the array of liposuction procedures available to the dermatologic surgeon. Minimally invasive and sparing of the breast parenchyma, breast liposuction has an excellent safety profile and rapid recovery time. Cosmetically elegant, it provides symmetrical results with barely visible scarring. Minor reductions in breast size in patients with normal shaped breasts will look better after liposuction alone than any other type of breast reduction surgery. Patients requiring change in the overall shape or orientation of the breasts and nipples, elderly patients, and patients requiring highvolume breast reduction should be referred to our plastic surgery colleagues for excisional procedures.7
- Baker TM. Suction mammoplasty: The use of suction lipectomy to reduce large breasts. Plast Reconstr Surg 106(1):227 (2000 Jul).
- Matarasso A, Courtiss EH. Suction mammoplasty: The use of suction lipectomy to reduce large breasts. Plast Reconstr Surg 87(4):709-17 (1991 Apr).
- Robertson JL. Changed appearance of mammograms following breast reduction. Plast Reconstr Surg 59(3):347-51 (1977 Mar).
- Abboud M, Vadoud-Seyedi J, De Mey A, Cukierfajn M, Lejour M. Incidence of calcifications in the breast after surgical reduction and liposuction. Plast Reconstr Surg :96:620-626(1995).
- Klein JA. Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St. Louis MO: Mosby (2000).
- Hanke CW, Coleman WP 3rd, Lillis PJ, et al. Infusion rates and levels of premedication in tumescent liposuction. Dermatol Surg 23(12):1131-4 (1997 Dec).
- Hidalgo DA, Elliot LF, Palumbo S, Casas L, Hammond D. Current trends in breast reduction. Plast Reconstr Surg 104(3):806-15 (1999 Sep).
FDA Strengthens Controls and Issues Consumer Alert on Importing Certain Prescription Drugs
As part of its ongoing efforts to reduce preventable adverse events from the products it regulates, the US Food and Drug Administration (US FDA) announced in December 2002, that it is strengthening the controls designed to protect patients by restricting imports of certain prescription drugs that can be used safely only with specified controls in place.
The FDAs action involves adding these drugs to an existing FDA Import Alert, which alerts FDA field personnel to the possible importation of these drugs, provides guidance as to their detention and refusal of admission into the United States. It also advises US Customs personnel to refer any attempted importation to the local FDA field office.
The drugs added to the Import Alert are as follows:
- Accutane® (isotretinoin) – indicated for the treatment of severe recalcitrant nodular acne
- Actiq® (fentanyl citrate) – indicated for the management of severe cancer pain in patients who are tolerant to opioid therapy
- Clozaril® (clozapine) – indicated for the management of severe schizophrenia in patients who fail to respond to standard drug treatments for schizophrenia
- Lotronex® (alosetron hydrochloride) – indicated for the treatment of severe irritable bowel syndrome in women
- Mifiprex® (mifepristone or RU-486) – indicated for the medical termination of early intrauterine pregnancy
- Thalomid® (thalidomide) – indicated for the acute treatment of the cutaneous manifestations of moderate to severe erythema nodosum leprosum
- Tikosyn® (dofetilide) – indicated for the maintenance of normal sinus rhythm in patients with certain cardiac arrhythmias
- Tracleer® (bosentan)- indicated for the treatment of severe pulmonary arterial hypertension
- Trovan® (trovafloxacin mesylate or alatrofloxacin mesylate injection) – an antibiotic administered in in-patient health care settings for the treatment of severe, life-threatening infections
- Xyrem® (sodium oxybate) – indicated for the treatment of cataplexy in patients with narcolepsy
In a related action, the US FDA today alerted consumers not to buy these drugs over the internet, because drugs obtained via websites usually are not accompanied by these safety controls. The FDA is concerned about the safety risks posed by use of any of these products without the specified controls in place.
Although these drugs have important benefits for many patients, they have serious known risks and so are available in the US only under specially created safety controls. These safety controls are bypassed when these drugs are purchased from foreign sources, placing patients who use these imported drugs at higher risk. Therefore, because of this higher risk to patients, the FDA took action to further curtail the products’ availability from foreign sources. The drugs purchased from foreign sources are generally not FDA-approved.
Controls on these prescription drugs include limiting their distribution to specific facilities (such as hospitals); limiting their distribution to physicians with special training or expertise; or requiring certain medical procedures (such as pregnancy testing or blood testing) with their use.
Detailed information for consumers and patients who would like to learn more about how to buy prescription drugs safely may be found in FDAs guide, “Buying prescription Medicines Online: A Consumer Safety Guide,” available online at FDA.gov/cder/drug/consumer/buyonline/guide.htm.
Source: US FDA News Release
American Academy of Dermatology Stresses the Safe Use of Botulinum Toxin
Since the Food and Drug Administration (FDA) approval of one form of botulinum toxin, it has been widely reported that patients are attending so called “Botox® parties” for the administration of this drug. Botulinum toxin treatments being performed in casual social settings rather than in a controlled medical environment contradicts the seriousness of this medical procedure.
As with any medical procedure, the possibility of adverse effects occurring from a botulinum toxin injection is always a possibility. Adding alcohol to the mix is a bad idea for a number of reasons, especially since bruising can be intensified.
Botulinum toxin is a purified form of one of the most potent toxins in the world. In high doses, it can cause the clinical disease botulism. However, when carefully injected by dermatologists and dermatologic surgeons in very low doses, botulinum toxin is a modern tool that can reduce the signs of aging. The American Academy of Dermatology (AAD) urges patients to select a qualified physician, such as a dermatologist, when considering this or any cosmetic procedure.
Because this is a quick method to treat wrinkles with no downtime, many patients are compromising their safety by having this medical procedure performed in an inappropriate setting, often by untrained medical professionals. To assist patients in choosing a qualified physician, the AAD recommends that before undergoing any cosmetic procedure, patients should ask the following questions:
- What are the doctor’s credentials? Is he/she a board-certified dermatologist or other appropriately trained surgeon? Ask to see their credentials.
- How many of these cosmetic surgery procedures has the physician performed?
- What results can be expected?
- How long is the recuperation period? Ask to see before and after photos of the physician’s previous patients.
- What are the risks?
- Where is the cosmetic surgery usually performed?
- What is the cost?
The AAD encourages all patients to consult with their dermatologist to determine which treatment is best for them. A wellinformed patient and a skilled dermatologist are always the best prescription for a successful outcome.
For more information, contact the AAD at 1-888-462-DERM (3376) or www.aad.org.
Source: AAD News Release