My Large breast or breast Hypertrophy is causing...
Waiting for ok from insurance :P
Waiting on Dictation?
I have lost 10lbs since February! YAY!!!
Last minute stuff pre surgery
2 days post op
I'm so Bloated!
Had a little scare today.
Blister and little hematoma
Can anyone say uncomfortable!
Feeling alot better today :)
Feeling a little swollen
Surgery day story :)
I have good days and I have not so good days
Do you ever think about getting a breast reduction revision?
A little sad :(
I've decide to be more positive about this.
The first BILL came!
Pictures 4 weeks!
6 weeks tomorrow and not too happy :(
On another note, my breast are doing good heal wise. They are still a little swollen, the right breast a little more then the left. A few days ago I had a small abscess on the out side of the right breast, where I had a stitch poking through. I popped it, pulled out the stich and cleaned the wound. I was going to wait until I saw my PS in November to have the stiches that are sticking out removed. But, after having one of them abscess I decided just to remove them my self. That's why I have a few band aids on my right breast. I went to my primary care doctor after wards and she said they are healing well and I can now start running if I want to. She also said now that I'm 6 weeks post op I can go bra shopping for normal bra's, not just sports bra's.
So I was excited to go bra shopping finally. We live in a rural area in Kansas, and the only store within a hour and a half drive is Walmart. I went to walmart and I must have tried on like 60 different bra's many different sizes. I even tried on girls training bra's. I went home with no new bra. When I got home I started crying :( Not one bra fit me. Not one size fit me. My breast were to wide for small cup sized bra's, and my breast were to flat to fill out large cup sizes. I was devastated. People always say, every bra is different, so its hard to know what size you are, but I tried on many sizes in every kind of bra, and none of them fit me, not even a little. My cleavage looked really bad in all of them too. I used to have a small amount of stretch mark's in my cleavage, and my breast reduction exacerbated them, and now all you see in the middle of my breast are large stretch marks. I can't wear low cut bra's. The only bra's that fit me are sports bar's. I even went on line and checked out how to properly measure your breast for a bra. I measured 32 C cup. But when I went shopping, I was too flat for a C cup, I was even a little flat in my left breast for a B cup. I hate to be such a downer. I know its still early, and my breast will continue to change, I'm just not sure if they will change enough to be a more normal size. Before my breast reduction I wasn't able to buy my bra's in store's, I had to special order them online. And now after my breast reduction I still cant shop for bra's in stores.
I tried to google lateral nipples and the only thing I could find was lateral nipples after a breast augmentation, not breast reduction. I cant even find anyone on this site with the same problem as me. I feel so alone :( I think I'm going to need another breast reduction to fix all the problems caused by my first reduction. My husband and I can't afford to pay for another reduction, and my insurance wont pay for another reduction. I'm not sure what my PS is going to say about all this. It's my fear that he will say he did his job and reduced my breast, and any asymmetry issues aren't his problem. They made me sign paper's pre operation stating that I understand some asymmetry is normal. I'd be ok with some asymmetry, but when I can't even fit in any bra other then a sports bra, something is wrong. He made my breast to wide, and my nipple/areola's too far apart. I hope he will offer to fix this issue for me, with low or no extra cost. That would be the right thing to do, but I'm just not sure what he's going to say until I see him in November. If he doesn't fix my breast, then I will still have to get them fixed, it may take me a few year's to afford to fix them though. I will have to live with messed up breast for a wile. I'm so embarrassed, I haven't told anyone about my misshaped breast, not even my husband. I feel so alone. I will tell my husband after I see my PS in November. This site is my only outlet for grief, this and crying alone in my bathroom.
I was saying that I would still do it all over again if I had the choice, but now I'm not so sure. I called my PS's office and spoke to his assistant. She said the breast reduction was to make my breast smaller for medical reasons, not cosmetic reasons. But he is a plastic surgeon, and they are in the business of making body's aesthetically pleasing right? So what went wrong with my breast? You know when your laying down on your back, and your breast fall to your sides, kind of into your arm pits, well I think that's how I must have been in the OR. I think he sewed them up as they laid on my sides, and that's why they are so lateral. I think he may have guesstimated where my nipples would be placed instead of doing actual measuring. If he doesn't offer to fix the problem, then I will have to see some other Plastic surgeons to get their opinion on my breast reduction.
I'm great full that my nipples work and have feeling, and that I didn't get necrosis of the breast. But, I'm left feeling a little deformed with the way they look now and with them not fitting into any bra size :(
I have been too overly emotional on this site.
The bill for the Anesthesiologist came
I know whats wrong with my breast reduction
Plastic surgery volume 5 edited & editor Neligan/Grotting
The appearance of the ideal breast is somewhat subjective. Each patient has their own opinion as to the aesthetics of their breasts, which should be given consideration with any operative alteration of the breast. Reconstruction or cosmetic enhancement of the breast encompasses not only the way the breast looks, but also how it feels to the touch. Size, symmetry, proportionality and the location of the breast and its landmarks on the chest wall all play a role in the attractiveness of the breast. Statistical standards for the dimensions of the breast have been analyzed and reported by various authors (Fig. 1.1).1–7 The distance from the sternal notch to the nipple and the distance from the midclavicular line are each 19–21 cm. The distance from nipple to the inframammary fold is 5–7 cm (Fig. 1.1). The distance from the nipple to the midline is 9–11 cm. These measurements offer guidelines for altering the breast, which must be individualized, based on proportionality, variances in chest wall anatomy, posture and patient preference (Fig. 1.2).
Statistical standards for the dimensions of the breast.
AP image: ideal breast dimensions demonstrating symmetry and projection.
The breast mound is situated over the pectoralis major muscle between the second and sixth ribs in the nonptotic state. Important landmarks include the upper pole, location of the nipple areolar complex, inframammary fold and lateral breast fold. The upper pole of the breast extends from just below the clavicle to the level of the nipple. The contour should be neither concave nor convex, but a plane that extends out to the point of maximum projection of the breast at the level of the nipple. In the ideal breast form, the nipple areolar complex should be cephalad to the level of the inframammary fold.
This is all from a book on the internet.
I marked my own breast
I'm finally going to see my PS!
Issues of Concern:
2 Months Post Op.
1. Lateral nipple areola complex (NAC), more so with Left nipple.
2. Lower cleavage line on the Right Breast, and lots of loose skin in cleavage.
3. 2 Strange unidentified spots on the inside and outside of the Left breast.
4. Right breast larger in volume on the outer edge, then the Left breast.
How could these issues be fixed?
How much to fix these issues?
How soon could these issue be fixed?
Ok that's all I can think of for now. I printed this list off to take with me so I wont forget anything. I'm also taking pictures with my questions I'll post those pictures for you guys to see. Any last minute helpful advise before I see him Wednesday, please post it for me. I really hope he will offer to fix many of these issues, cause I can't afford another surgery. I haven't even told my husband about any of my problems. I've been waiting until after I see my PS to know what can be fixed. I'm nervous about what I'm going to say to him about my breast too. He hasn't seen them or felt them or anything. He just keeps saying "I hope there worth it" he's referring to the cost of the bills for my breast reduction. So I will open up to him about all this that I've been going through and what can be done to fix it. Wish me luck, I'm going to need it.
I couldnt be more disappointed
Progress report 11weeks post op
All the Bills are in!
12 weeks post op pictures :)
My uneven cleavage
I tried bra shopping again
Today is my birthday :)
My Surgeons Operative Notes
It said prior to surgery , the day before surgery, the patient had a Modified Wise Pattern designed on her breasts. I found that to be less then factual. As you can see the markings in the picture I took the morning before my surgery, were incomplete markings. He did mark me in a standing position with a permanent black marker (not meant for use on skin). He did not take into account my Mid-Sternal line. In fact when he was making those lines on me he was free drawling them. He did not measure me out from my Mid-Clavicular line. He told that I could take a shower pre surgery but, try not to wash off the lines. Honestly I thought he was joking, these couldn't possibly be my only pre surgery lines. And I remember laying on the bed before being wheeled in to the OR, telling him that I was sorry I washed most of the lines off. He told me not to worry about that. I was so nervous about going into surgery that I didn't think to ask him to re-draw my lines. Most surgeon make sure your lines are ready before going under the knife. The notes then say informed consent was obtained and the patient was taken to the OR. By the time the nurses wheeled me to the OR door I was out. It was the last thing I remember before waking up in recovery. The notes go on to say the patient was placed in a Supine position (Laying on your back with face upward). The notes then say the Marks were then reinforced on the chest wall with a marking pen. If we are to believe this statement to be factual, then he just marked me laying down on my back face up. Most of us aren't doctors on here, but it is common knowledge that you don't mark the patient laying down. Dr. Joseph Rucker informed me when I asked the question on Real Self, Why Plastic Surgeons mark patients in an upright position or standing position. He said, If marked in the SUPINE position the breast fall to the side and this will give a distorted final determination of the new position of the nipple (NAC). And this is why my breast look like the were put together on my sides under my arm pits and not out in front of my torso. With all of Dr.Tirre's experience he should have none not to do that. If these notes are accurate then that's gross negligence. I could have had a chance at having a normal breast reduction with normal results and he took that from me, with this careless mistake. The notes then go on to say, the chest wall was prepped with Betadine (prevent infection). Attention was first turned to the right breast. The base of the inferior pedicle was marked with a width of 9cm. 45mm nipple areola template was then used to design the nipple areola incision with a 10-blade knife. The inferior pedicle was de-epithelialized (un covered) with a 10-blade knife. The medial, middle, superior (upper), and lateral (sides), skin flaps were elevated a uniform thickness utilizing electro-cautery (electronic burning knife). I'm pretty sure I was not informed of the possible complications that come with using this form of cautery, like burns, skin & fat necrosis, and scaring. I believe consent prior to having a procedure with electro-cautery should have been obtained. I don't remember anyone speaking to me about it or me signing consent to use such tools, so that's something to look into. I now believe that the marks of fat necrosis on my upper inner and outer quadrant or upper poles could have been caused by the electro-cautery. The notes go on to say, dissecting between the breast tissue in the subcutaneous fat was done down to the pectoralis fascia, and the pedicle was de-bulked. The inframammory incisions were then made with a 15-blade knife. The medial and lateral skin flaps were elevated. The nipple areola was then tagged with 2-0nylon sutures. A #10 flat Jackson -Pratt drain was then brought out through a separate wound laterally. Position done on the skin flaps. The notes then state the Pedicle and Nipple -areola were buried and the skin flaps were brought to the Mid line under minimal tension using the 2-0nylon sutures. So he buried the pedicle and NAC under my breast with what Im thinking if Im understanding this correctly, is the skin flaps brought together at the middle of my breast ( the middle of my breast in a laying down position), and then put them together with a suture (stich). The notes then say he moved to do the same with the left breast. After doing all the same stuff to the left breast he then irrigated the area with normal Saline. I have know idea why. The notes go on to say a Flat Jackson-pratt drain was brought out through a separate stab wound. The left nipple areola was then tagged with a 2-0nylon suture and the skin flaps were brought to the midline ( or what he assumed the mid line would be with me laying down). And the nipple areola was buried under the skin flaps. At this point the patient was sat up and placed in a sitting position. The excessive skin bilaterally (on both sides) on the medial and lateral skinflaps was then marked with a marking pen on both the right and the left. On the right breast excessive (extra) skin was excised using a 10-blade knife and with hemostasis (the stopping of bleeding), he used electro-cautery. He then did the same thing to the Left breast. He then placed me in a SUPINE (laying with my back down and face up) position. Simultaneously (at the same time) the inframammary incisions were approximated ( I believe this means he was making sure the incisions under my breast were both even, and he decides this as I am laying flat on my back instead of an up right position with would have been the proper thing to do, and that's probably why my cleavage was made so uneven). He approximated using interrupted 3-0 monocryl sutures in interrupted inverted( upside down or opposite position) fashion. The vertical slit incisions were approximated with interrupted 3-0 monocrly sutures. So what I think this means is the line that go's vertical or straight down the middle of your breast is what he was making sure were even with each other, again while Im laying back down face up. Next attention goes first to the right breast, a 38mm nipple areola template was used to mark the key-hole incision approximately 4.5cm above the inframammaryfold. So at which point did he decide where to mark the key hole? If these notes are correct it was while I was laying down face up. This is the point he decides to mark my new NAC with me laying back down. He approximated the midline and vertical slit with me laying down and then put my new NAC with me laying down on where he believed to be the middle of my breast. The middle of my breast would have been in a different spot when I was in an upright position then laying down with my breast at my sides in my under arms. Once again Dr. Joseph Rucker said in a SUPINE position the breast fall to the side and this will give a distorted final determination of the new position of the nipple (NAC). The notes go on to say this was cut with a 10-blade knife the skin and the subcutaneous fat was excised (cut out). The nipple areola was then brought out ( of the hole he just cut) and inset with interrupted 3-0 monocryl sutures in setting the dermis ( skin). Then he did the same thing to the left. The notes go on to say the total weight taken from the left (the smaller breast to start with) 557g and the larger breast the right he took 547g out of. Again why would you take more out of the smaller breast and less out of the larger breast? Gross incompetence, I believe or a lack of paying attention to detail. Because he did that I'm left with two different sized breast with out being able to fit in a normal cup bra. If he paid attention to this details I wouldn't need to get lipo suction or what ever else I will have to do to even up my breast size. The notes go on to say all the incisions were then approximated (to come close to being similar) using running subcuticular 4-0 monocryl sutures. And Derma bond was placed on the skin over the incision lines ( skin glue). The drains were hooked up to the bulbs and the patient was brought to recovery without complication. If these notes are accurate then we can all see what really happened to my breast and why they appear the way they do. I feel so violated. If he only to proper procautions these mistakes would not have happened and I'd be telling all of you how wonderful my new breast are and how much I love them :(
Operative notes & my question answered by dr.'s on realself
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Why do you mark the patient standing up prior to Breast Reduction Surgery?
Asked by HappliyMarried33 in US
3 days ago
Why do you mark the patient standing up instead of laying down, prior to Inferior Pedicle Wise Pattern Breast Reduction Mammoplasty? Does it matter whether your laying on your back or are in a standing position when your being marked pre surgery? Or is it not that big of a deal, cause if your Surgeon's Board Certified, he is so skilled he can mark you in any position.
6 doctor answers:
I guess ever since the pyramids were built, breasts have been marked in the upright position. So part of the answer is that that is the way we always do it. But the other side of the answer is that when the patient is lying down we also assess and adjust the markings a bit. Breast reduction marking is very important. Another twist on this is that
in the upright position the breasts are stationery and comparable to each other. The surgeon can clearly measure from the sternal notch, and the 6 th rib, and the ziphoid angle and the middle of the arm. All this becomes vague and hard to compare when reclined. Then again another answer is that for all the above reasons, marking in the upright position is just better. I usually have the patient sit upright and not stand. I have seen surgeons take over an hour to mark breasts. This is fine. Most of us take 10 to 15 minutes at most. My best, Dr C
George Commons, MD
Palo Alto Plastic Surgeon
Why Plastic Surgeons Mark Their Patients in the Standing Position Prior to Surgery.
I have performed approximately 2,000 breast reduction surgeries and I prefer to mark the patient in the standing position for the following reasons.
1. If marked in the supine position the breast fall to the side and this will give a distorted final determination of the new position of the nipple.
2. I prefer standing as opposed to sitting because I prefer the abdominal tissues (which are forced upward during sitting) to not effect the markings.
Web reference: http://drrucker.blogspot.com/2013/11/when-insurance-covers-breast-reduction.html
Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
Marking breasts before breast reduction surgery
Although, all pre surgical markings are important, I also take into consideration what effects gravity has on the part in question when you are lying on the table. As you know, breasts tend to fall on the sides of the chest when lying on your back. I have made certain that with the Ultimate Breast Reduction technique, breasts are not subject to the forces of gravity.
Plastic surgeons need to look at all aspects of esthetic improvement. This not only requires having an esthetic eye, but technical ability and know-how.
Hope this helps.
Web reference: http://www.fastcodesign.com/1663319/how-one-surgeon-is-reinventing-the-female-breast-sfw
Gary M. Horndeski, MD
Texas Plastic Surgeon
Marking for Breast Reduction
I prefer to mark the patient sitting. This allows me to factor in the effects of gravity on the breasts.
Earl Stephenson, Jr., MD, DDS
Atlanta Plastic Surgeon
I mark patients while sitting...
Hi HappilyMarried33. There are many ways to mark patients, and none of them are right or wrong. I was trained to mark patients while they are sitting. This has worked well for me over the last 700 or so cases. Other surgeons probably have equally good results marking patients in other positions.
Lewis Ladocsi, MD, FACS
Richmond Plastic Surgeon
Marking is a personal thing. I prefer to mark the patient in the standing position because it takes gravity into account and allows me an opportunity to account for that as I try and provide the best symmetry. I have seen very skilled plastic surgeons who do not mark at all and get excellent results. I think whatever the surgeon you chose does routinely to get good results is important.
All the best,
Arun Rao Plastic Surgeon Tucson, Arizona
Arun Rao, MD
Tucson Plastic Surgeon
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.
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17 weeks or 4 months :)
I just read the saddest thing
I'm so sorry that Dena33 had to go through that on this site. If any of you can please post something nice on her review. She has had to live all these years with her poor results because she never had the money to fix them. I told her how bad I felt for her situation, I couldn't imagine going 15 years with these results. What that must have done to her self esteem. I told her I would pray for her it moved me so much :( I really hope nothing like that happens to any of you. If your doctor gives you a poor outcome and then won't fix that outcome, and you give them a poor review, you should know you have the right to do so. As long as your being honest about it there's nothing they can do about it. If they don't want their reputation being damaged by a poor review then they need to give better results and treat their patients with understanding and dignity. I didn't want to give a poor review. I wish I could have given a better review. I wish I had better results or you offered to help fix my poor results. I gave my review and I would have even gotten rid of it when I noticed the review was starting to go south. But I couldn't. Real self said the review was staying. After you treated me so poorly I wasn't concerned how this review made you look. You didn't care how I looked so why should I care how you look anymore. I have to look at what you did to me everyday, do you have to look at my review everyday? Post what you want on my site. If your embarrassed with my review then you should be. I'm embarrassed at the way my breast looks, I'm embarrassed that I trusted you.
Pre-Surgery Marking and Planning
More picture art
When does your surgeon locate the new NAC?
When does your surgeon locate the new position of the NAC? Before or during your Breast Reduction?
Doctor Tom J. Pousti MD, FACS
January 30th, 2014
In all aspects of plastic surgery procedures, there may be different methods that different plastic surgeons utilize. In my practice, and most plastic surgeons' practices I know, breast reduction pre operative markings allow for measurements and planning/positioning of the nipple/areola complexes. Best to run this question by your chosen plastic surgeon for accurate/relevant information. Best wishes.
Web reference: http://www.poustiplasticsurgery.com/Procedures/Procedure_breastReduction.htm
Nipple Location With Breast Reduction
Doctor John Whitt MD
January 30th, 2014
I always mark my reduction patients pre-op based on where I would like to see the NAC post-op. The final determination is made during the procedure, but any difference is usually very slight and the pre-op marking is important.
Doctor C. Andrew Salzberg MD
February 4th, 2014
Thank you for your question. Usually, the breasts are marked with the patient awake, sitting or standing upright, prior to the procedure. Markings include the position of the NAC. However, all surgeons are different, so I would discuss this with the plastic surgeon you choose prior to the procedure to better understand his method.
My PS re-marked the lack there of, marks he made on me the first time, when I was in a supine position under anesthesia in the OR. Yesterday, I marked my self with a permanent marker like the one my PS used when he marked me the first time. And then I took a picture of the mark, before I got in the shower today. I washed my body like normal, the same way I did the morning before surgery. I then got dressed and took another picture of the mark. I did this to show that the day of my surgery most of my marks washed off, and that's why he had to reinforce them on the OR table while I was in a supine position. He marked me laying down, just like he marked the new NAC while I was laying down later in surgery. I looked at many women after they get out of surgery and a lot of them still have marks on their skin in their after pictures. I remember not having any marks any where on me right after surgery. If he re-marked me, he must not have done much more then what he did the day before, cause I had no marks any where, not above or below my breast. All his marks must have gotten cut off. Its weird cause most other women still showed a lot of their marks that were still left on their torso's. Ok well I'm done beating this horse for now. Ha Ha get it, beating a dead horse. If I'm tired of writing about it, I know you guys have got to be tired of reading about it. If I run across anything new, I'll be sure to keep you all informed. Happy Healing :)
I found this on Lubin & Meyer Malpractice Law
botched breast surgery
Medical Malpractice Trial Lawyers Report, 2006
Loss of Both Breasts Following Breast Reduction Surgery
The plaintiff was a 63 year old woman who had undergone breast reduction surgery in Canada when she was 18 years old. After the passing of many years, and after birthing three children and gaining forty pounds, her breasts had grown large again and she was experiencing neck, shoulder and back pain. She went to see the defendant plastic surgeon in October, 2002, to discuss a second breast reduction operation.
The defendant proceeded with breast reduction surgery in December, 2002. The defendant assumed the records from Canada were not available, and did not attempt to obtain these records. There was a factual dispute whether the plaintiff was able to remember the details of the prior breast reduction in Canada, and whether she discussed the details with the defendant prior to the surgery in 2002. The defendant claimed to have asked the plaintiff questions regarding the prior surgery so the defendant could try to obtain those records, but the plaintiff could not provide enough information to allow the defendant to request the records.
The defendant performed the breast reduction, without the prior records, using an inferior pedicle technique. In simplest terms, this technique removes tissue from the top of the breast and preserves blood flow on the bottom of the breast. It is an excellent technique and the most common approach in use in 2002 and today. The plaintiff was able to show, however, that in the early 1960's the predominant method for breast reductions was a superior pedicle technique in which tissue is removed from the bottom of the breast and blood flow is preserved on the top of the breast.
The plaintiff claimed that the standard of care in a repeat breast reduction was to utilize the same technique that was used in the prior breast reduction. The plaintiff further claimed that in cases where the prior technique could not be determined, the standard of care was to perform a free nipple graft. The plaintiff alleged that because the defendant used the incorrect technique, she was caused to suffer a lack of adequate blood flow to her breasts resulting in tissue necrosis. The plaintiff subsequently required what was essentially a double mastectomy to remove the necrotic tissue.
The defendant claimed that while there was certainly an unfortunate and undesired result, the defendant fully complied with the standard of care at all times. The defendant also pointed out that there were lengthy discussions about the risks of the procedure, and that those discussions were documented in the medical records of the pre-operative office visits. Among the risks discussed and documented were tissue necrosis and the need for further surgery. The defendant also claimed that the plaintiff may well have suffered the same outcome regardless of which technique was used in 2002.
The case was tried over five days. The jury deliberated for four and half hours before returning its verdict. The jury found the defendant was negligent and that the defendant failed to obtain the plaintiff's informed consent. The jury awarded the plaintiff a total of $3,000,000 for past and future scarring, disfigurement, and pain and suffering. The jury also awarded $500,000 to the plaintiff's husband for his loss of consortium claim.
I just thought I'd share this story with all of you. It shows the importance of having all your previous medical records, before getting a breast reduction revision, or added breast work after your first reduction.
Wise Pattern Breast Reduction with Inferior Pedicle
Wise pattern breast reduction through a keyhole incision and inferior pedicle is the most versatile breast reduction technique, applicable to the broadest range of patients.
Wise pattern inferior pedicle breast reduction is very good for the majority of women seeking breast reduction. Whereas classical literature claims a limit of nipple elevation of 16 cm, we have found success in up to 20 cm of elevation. Wise pattern breast reduction addresses axillary fullness well
The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed below the level of the inframammary fold (IMF). The new nipple position is marked on this axis at the level of the IMF, often 22-23 cm from the sternal notch. Limbs of 8 cm in length are designed from the nipple to define the new nipple-inframammary distance, and the distance between these two limbs varies depending upon the width of the nipple areolar complex and the degree of breast narrowing the surgeon aims to achieve, usually on the order of 7-8 cm. Symmetry can be checked by comparing distances between each distal limb to the sternal notch with a tape measure. A wire nipple marker can be used to mark the ultimate 4-cm nipple areolar complex (NAC) centered around the apex of the limbs drawn. The IMF is marked. Markings then connect the distal portion of the limbs medially and laterally to the IMF. An inferior pedicle is marked symmetrically on the two breasts, at least 7 cm in width (Figure 16-1). The new nipple areolar position is measured again as well as the existing NAC position to determine preoperative asymmetry. This should be confirmed with the patient. Once the patient is asleep on the operating room table, the symmetry of markings may be further checked, ensuring that the distance from midline to the central breast axis is the same, as well as the distance of the pedicle from midline and the width of the pedicle
DETAILS OF PROCEDURE
The patient is brought into the operating room and anesthesia is induced. A Foley catheter may be placed to monitor urine output, particularly if the case will last longer than 3 hours. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to pre- vent nerve compression. The knees are placed on a pillow to encourage ?exion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. Markings on the breast are deter- mined to be symmetric with regard to midpoint marked on the IMF on each breast and the width and position of the inferior pedicle centered on the central IMF marking. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. The drapes on the chest should be stapled into position, stapling superiorly on the clavicles and stapling the central axis of each breast above the pro- posed NAC complex and below the IMF. A 42- to 45-mm nipple areolar cookie cutter is used to designate the new nipple areolar diameter, and this mark is incised with the NAC on moderate stretch (Figure 16-2). The central pedicle is then de-epithelialized with a knife or with large mayo scissors, preserving the NAC (Figure 16-3).
After this, the cautery is used to resect breast and skin of the medial and lateral triangles (Figure 16-4A, B). Skin ?aps are developed superiorly as these triangles are excised, at least 2 cm in thickness, making the resection specimens’ shape resemble tetrahedrons. The medial and lateral triangles of tissue are excised from the central pedicle laterally, ensuring that excellent blood supply is maintained on the pedicle. The new NAC and vertical limbs are then incised, connecting into the medial and lateral resection areas. The superior breast skin ?aps are elevated as far as necessary to comfortably accommodate the breast tissue, up to the clavicles and above the pectoralis fascia. Breast tissue may then be resected superiorly from the inferior pedicle with the cautery or a dermatome blade, and further removal laterally and medially from the pedicle is performed (Figure 16-5). Careful hemostasis is achieved and the wound is irrigated. Intercostal blocks may be placed with lidocaine, bupivacaine, or a mixture of the two for postoperative comfort below the ribs. Dermal sutures (#3-0 monofilament absorbable) are then placed to approximate the skin ?aps centrally under the NAC and at the fold. Staples may then be used to approximate the inframammary closure. A 10-mm ?at Jackson-Pratt drain is placed, exiting out the lateral position and sutured into position with a #3-0 permanent monofilament suture. The patient is ?exed on the operating room bed to elevate the back and assess sym- metry, and any necessary revisions are performed. The weight of tissue removed from each side is compared and should be similar unless there was remarkable preoperative asymmetry. The skin ?aps vertically and horizontally are approximated with buried dermal interrupted #3-0 monofilament absorbable sutures, as is the NAC. A #4-0 monofilament absorbable running intracuticular suture is placed (Figure 16-6). Interrupted #4-0 monofilament permanent sutures may be used to reinforce closure. The wounds are then washed and dressed with petrolatum gauze and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight. The patient should then be extubated and the urine catheter removed if one was placed at the beginning of the case.
Breast reduction as a solo procedure may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral ?uids. The patient may stay in the hospital overnight for monitoring, intravenous antibiotics, and pain management. If the patient stays in hospital, the drains are often removed the following morning. If out- put overnight is more than 50 cc, the drains may be left in for a week until the first postoperative visit. Oral antibiotics should be considered until drain removal.
The patient returns 1 week after surgery for the first postoperative visit. Sutures are removed, and drains are removed if still in place. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and a soft support bra is recommended for 2 months.
Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If small open wounds occur, most often under the NAC or at the IMF, they are treated locally with antibiotic ointment, cleansing, and bandaging.
This technique has been most criticized for its scars and ?attened breast contour. The scars that are most problematic lie along the IMF medially and laterally and around the NAC. Scars may be particularly problematic when central inferior scars are connected across the lower sternum when symmastia is treated. Scars may be thicker if there is secondary wound healing. The scars require aggressive postoperative management. The contour associated with this technique is ?atter than that associated with vertical techniques, but the benefit in this technique is the vertical reduction in breast length that can be achieved and the symmetry that is easily attained.
Careful attention must be paid to not making the NAC too high. A high NAC may be hard to hide in a bra or swimsuit top and is not easy to correct. The patient must understand how far lateral the incisions will go as they may be visible in revealing clothing.
If this is a secondary breast reduction it is very important to ensure that the prior pedicle is not disconnected, no matter how much time has passed since the first procedure. As much information about the initial procedure should be gained to protect against complications, including if there were complications associated with the initial procedure, such as large seromas or hematomas. Secondary breast reduction has much higher risk for complication than primary breast reduction.
The most common complication of Wise pattern breast reduction is wound healing problems with skin necrosis centrally where the skin ?aps are approximated and tension is the greatest. Adequate thickness on skin ?aps and minimizing risk of overresection of skin must be ensured to allow optimal healing.
Careful patient selection is important in ensuring success in this case. The skin ?aps are elevated and under- mined, leading to significant compromise of vascularity and potential skin loss along the medial inferior skin ?aps. Patients who smoke, have coronary artery disease, have autoimmune disease requiring steroids, are diabetic with poor glucose control, have psychiatric problems, or are older than 50 years are at elevated risk for healing problems. Patients who are morbidly obese, particularly teenagers, should be referred for weight loss prior to breast reduction.
With congestion of nipples or a seemingly tight closure, leaving incisions open either around the NAC or throughout the breast allows for swelling, and closure may take place at a later time. Nipples may be converted to grafts if there is an obvious problem with circulation. This possibility should be anticipated in larger breasted patients with medical comorbidities, and the patient should be prepared for the possibility of nipple grafting.
Always underresect rather than overresect in creation of incisions, the inferior pedicle and skin ?aps. One can always go back and remove more, but once the tissue is gone, it is gone.
In teenagers presenting for breast reduction, scars must be reviewed with the family and potential patient so that they understand what is involved. Teenagers may not be accepting of the scars. Teenagers with macromastia may be prone to recurrent macromastia, so this possibility needs to be discussed as well.
This was written by Dr. Adarsh Patil November 20, 2012
I found it on the internet, and wanted to share it with all of you, since this is the procedure I had, well or was supposed to have, not sure about how much Dr. Adarsh surgery is like Dr. Tirre's surgery he preformed on me. I will need to take a closer look to compare the two.
Thank you Real Self :)
I have given this a lot of thought. Now that I'm 4 1/2 months past, I'm very unsatisfied with my Breast Reduction results. I believe Dr. Tirre could have done a better job, so I personally would not recommend him for Breast Reductions.