In 2001, after 4 years of performing breast reduction using my lipoplasty-only technique, I published my technique and results in Aesthetic Surgery Journal. During that period, I was using lipoplasty-only exclusively in all patients who requested breast reduction. Since that report I have performed an additional 276 procedures and, as a result, have somewhat modified my approach. Here, after performing a total of 751 breast reductions, I report on my modifications.
Since 1997, when I first presented this technique, lipoplasty-only breast reduction has continued to gain acceptance. In addition to my own reporting on this technique, others have also demonstrated its effectiveness and safety. In my practice, currently, 85% of breast reductions are performed using the lipoplasty-only technique. The average volume removal is 800 cc per breast with a range of 75 to 4200 cc of pure fat.
Until 2 years ago, I offered all of my patients a secondary mastopexy procedure in the event that they were unhappy with the amount of residual breast ptosis, but only 7 patients requested a secondary procedure. (Another 2 patients, young women with inadequate volume reduction, underwent conventional breast reduction subsequent to the lipoplasty-only procedure). After some time, I began to realize that some women declined lipoplasty reductions and did not schedule surgery because they were concerned that by undergoing lipoplasty-only, they would be left with residual ptosis and they did not want to return for an additional operation. Based on this observation, I began offering the option of a vertical mastopexy performed in the same session with the lipoplasty reduction, and in some cases, I simply recommend a conventional breast reduction in lieu of the lipoplasty-only procedure.
I have made a number of changes in my methods of preoperative evaluation. In the past, I required a mammogram in patients older than 40 solely because I wanted them screened for breast masses. However, after viewing several hundred mammograms, it became apparent that mammograms provide a useful tool for estimating postoperative volume by revealing the breast fat content. I now ask for mammograms in all thin patients. Also, I have been treating an increased number of patients with massive weight loss and find mammograms helpful in assessing the optimal approach in this population.
Although most patients have sufficient fat for at least a one-cup-bra reduction with lipoplasty, I have found that about 10% have breast tissue that is too dense. For these patients, I recommend a conventional reduction. In addition, I will typically offer a conventional reduction to patients who wish to be reduced more than 1 bra-cup size.
A patient who is planning to have excisions in other anatomical areas and is more accepting of scars may be perfectly happy choosing a conventional breast reduction. If there is minimal breast tissue with marked excess skin, such as in some patients with massive weight loss, I do not perform a lipoplasty-only reduction; a conventional reduction will provide a much better result.
My approach to correcting breast asymmetry has also changed. I am utilizing lypoplasty-only procedures more frequently to address this problem. Many patients choose a unilateral lipoplasty reduction, rather than undergoing augmentation, to avoid the risks of capsular contracture or implant failure.
To summarize, since my last report in Aesthetic Surgery Journal, I have modified my approach in the following ways:
1. While still performing, approximately 85% lipoplasty-only procedures, I now discuss with my patients the possibility of a vertical mastopexy performed in the same session, rather than suggesting that a 2-stage procedure may be necessary.
2.I frequently use mammograms as part of the evaluation process to help assess breast fat volume.
3.I may elect to perform conventional reductions if the patients desire more than a 1-bra-cup size reduction, has very dense breast tissues, is having other excisional contouring surgery, or has minimal breast tissue with significant excess skin.
4.I increasingly use a unilateral lipoplasty procedure to correct breast asymmetry, allowing patients to avoid the possible complications of augmentation surgery.
Technique:
There has been no change in my technique for performing lipoplasty-only breast reduction. I do not use ultrasound-assisted lipoplasty (UAL) in the breast.
In performing a vertical mastopexy with a lipoplasty reduction, you can anticipate a 3-cm improvement in nipple position when you mark the patient compared with a 5-cm improvement using lipoplasty-only. Because of the skin excision, there is less contraction. After the infiltration it is easy to deepithelialize. Follow deepithelialization with the lipoplasty reduction. Do not undermine.
Place a 2-0 supramid suture in the dermis, medial to the excision, and tighten it to the proposed areolar diameter. Perform the remaining dermal repair with Vicryl or Monocryl (Ethicon Inc., Sommerville, NJ). Close the skin with 5-0 nylon. Postoperatively, I treat patients undergoing vertical mastopexy with lipoplasty reduction in the same manner as patients who have undergone a lipoplasty-only procedure. I change dressings as necessary. Patients use antibiotic ointment on the incisions until the sutures are removed after 5 days. I do not allow strenuous activity for 1 week after surgery.
Results
Since I stopped exclusively performing lipoplasty-only breast reductions, I have performed conventional reductions in 5% of patients and lipoplasty with vertical mastopexies in 10% of patients. Because there is no undermining or flaps, there has been no dehiscence, nipple necrosis, or numbness. During the past 2 years, I have had only 1 complication, an infection that responded to antibiotics. I continue to perform lipoplasty-only reductions in 85% patients. Even though the vertical mastopexy has been a safe and effective procedure, most patients would rather avoid the additional scarring. Most patients are pleased to eliminate symptoms and are not overly concerned with ideal nipple position.
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