Breast Reduction

Thank you Real Self for giving me an opportunity to learn from and be apart of your community. I found Real Self after deciding that last year, would be the year for me to pursue my life long dream of getting a breast reduction. I wanted to have a Breast Reduction since finding out about them in my late teens. Finally at 33 I was going to purse this dream, but I had no idea where to begin. Thank goodness for the internet, without which I wouldn't have had much knowledge on what to do and how to pursue getting a Breast Reduction. I first needed to figure out how to get insurance to pay for my reduction, and that took many months of hard work and research. After which, I did what most insurance company's require you to do in order to qualify for coverage. While I was busy with all of that, I was also researching other women's Breast Reduction experiences, so that I would be ready if and when I was able to qualify for a reduction. I cant tell you how much Real Self helped me with that. Real Self has the largest amount of personal experience's shared by the most wonderful women. Some of whom had positive experiences and some had negative, but all of their collective experiences helped me in preparation for my own. Your team created this wonderful and safe atmosphere for which I'm eternally grateful. The Real Self Staff and the Real Self Community has helped me so much through my own personal Breast Reduction journey. I tried to be as open and as honest with my experience as possible. I really was hoping to have a happier more positive one. I choose the wrong surgeon for my procedure and have been paying for that mistake ever since. But without your community I would have been so alone in my despair. Your Community has been my closest kindred friends. For me my botched cosmetic procedure was humiliating and I really didn't want to share it with too many of my friends and family. Not too many of them supported or understood my decision to have this procedure done. But your community supported me every step of the way. They comforted me when I was at my lowest, and for that I'm so grateful for. Real Self isn't just a place where you can learn about different procedures, its a place where kindred spirits come to connect and guide each other through our body and souls transformations. You haven't just created an amazing company, but a wonderful loving and supportive family. After my botched procedure, I was devastated. I needed to understand why and how this happened to me, and I wanted to help other women avoid the same mistakes I made. The more I learned the more I shared. Thank you for providing me with the chance to ask Doctors in the field of plastic surgery questions that helped me to understand more about the procedure I was to have, and had. There can never be too much information on the internet. Your Doctors give great advise, weather or not that advise was what I wanted to hear at the time. We don't always know what's best for us, but thank goodness for your wonderful team of professional's who are there to guide us along our complex journey. I wish my review would have been a more positive one, but I am very hopeful for the future. I know I will have the breast I've hoped for most of my life, its just a matter of time. I learned from my mistakes and I hope I was able to help others be more informed about how they can prevent those same mistakes from happening to them. I will chose a much better surgeon next time. I spent most of my life in more populated places, mostly in the Pennsylvania, Florida, and Nevada. I now live with my husband and his family in a very rural part of Kansas. We are hundreds of miles from big towns and city's. Our town is like an island in the corn fields with only 5- 6,000 people for hundreds of miles around. Without Rea Self, I never would have been able to ask questions and get answers from professional and experienced Doctors in the field of plastic surgery. I can never say thank you enough, please share my thank you with the whole team. All of you have had a hand in contributing to a remarkable human experience. You are all appreciated in everything that you do for the Real Self Community. Thanks again, HappilyMarried34 :)

INTRODUCTION

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.

INDICATIONS

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

MARKINGS

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.

POSTOPERATIVE CARE

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.

PITFALLS

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.

TIPS

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.

Jury awards $3.5 million to woman in
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.