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).



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



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.



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.



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.



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.

2.7 breast reduction, edward p. melmed

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