Breast reduction surgery has achieved one of the highest patient satisfaction rates among plastic surgery procedures. Most of the complications encountered are usually minor and related to wound healing. Revision surgery to address these problems is common and usually consists of scar revisions. Postoperative breast asymmetry of a mild degree is also common; however, postoperative asymmetry severe enough to warrant surgical revision is a rare event, occurring in less than 1% of cases. Postmammaplasty revision surgery needs to be individualized. The asymmetry could be the result of nipple malposition or it could consist of a volume or shape discrepancy between the breast mounds.
Key points
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Liposuction is an effective way to correct asymmetries of volume between the breast mounds. Ultrasound-assisted liposuction may be less traumatic.
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Implantation of an acellular dermal matrix or an absorbable mesh may be useful in cases where lower pole support is needed.
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Nipple malposition almost always involves high-riding nipples. Be mindful of the desired nipple position during the preoperative markings.
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A photograph grid is an effective way to assess preoperative and postoperative breast asymmetry.
Introduction
Reduction mammaplasty is currently the sixth most common surgical procedure performed on women by members of the American Society for Aesthetic Plastic Surgery. That same society reported 114,470 cases performed by its members in 2014. Breast reduction surgery has achieved one of the highest patient satisfaction rates among plastic surgery procedures with 93% to 97% of patients indicating that they would undergo the procedure again. The fact that this procedure enjoys tremendous success among patients despite reported complication rates of 53% is a testament to the efficacy of the operation in relieving the symptoms associated with macromastia and plastic surgeons becoming more adept at managing the more common postoperative problems associated with the surgery. Although complication rates reported in the literature range from 6% to 53%, it is most likely that with careful scrutiny of postoperative results the overall complication rate for this operation will approximate the 43% figure quoted from the analysis of the BRAVO (Breast Reduction Assessment: Value and Outcome) study. By far the most common complication reported in the literature is delayed wound healing followed by suture complications, hematoma, hypertrophic scars, nipple necrosis, fat necrosis, and seromas. Postoperative asymmetry is hardly ever mentioned in published series of breast reduction outcomes.
The possibility of postoperative breast asymmetry is always discussed with the patient as part of the preoperative informed consent process. Although it is currently the first complication listed in the breast reduction consent form created by the American Society of Plastic Surgeons, postoperative asymmetry requiring surgical revision is a rare event, occurring in less than 1% of cases. Currently, high-definition digital photography and standardized grids allow surgeons to critically assess their postoperative results ( Fig. 1 ). Under these conditions the surgeon frequently notices minor asymmetries in nipple position, volume, or shape of the breasts; however, asymmetries noticeable enough for the patient to request revisionary surgery are a rare occurrence. Only one case of postoperative asymmetry was reported by the BRAVO study consisting of 179 patients. A review of my last 267 breast reductions revealed only two revisions related to postsurgical asymmetry, one for nipple asymmetry and the other for unilateral bottoming out phenomenon resulting in a noticeable shape asymmetry. After reviewing my cases I was convinced that the low revision rate for asymmetry was mostly caused by personally performing all my preoperative markings and the major portions of the operation on both breasts, consisting of the tissue resection and shaping. However, at our local plastic surgery training program at the University of Miami, School of Medicine, it is common for two surgeons to work simultaneously during a breast reduction. As in most plastic surgery training programs, it may be a resident in training working on one of the breasts. Even under these circumstances, significant postoperative breast asymmetry requiring revision remains a rare occurrence. In the past 3 years and more than 200 cases, there have not been any operations performed at that institution solely for the purpose of correcting post-breast-reduction asymmetry. This favorable experience is in contrast with a recent study reporting a 15% rate of significant asymmetry following vertical reduction mammaplasty. Regardless of the technique used, appropriate preoperative markings and strict adherence to the markings during the surgery are still some of the most effective ways to prevent postmammaplasty asymmetry.
Breast asymmetry following reduction mammaplasty may involve the nipple-areolar complexes, differences in breast volume or shape, and/or location of the inframammary folds. Asymmetry that is noticeable early in the postoperative period is often the result of incorrect preoperative markings or poor surgical technique. Significant breast asymmetry may also occur years after a satisfactory initial result. Major weight fluctuations, pregnancy, or the long-term effects of aging can contribute to late asymmetry. Fig. 2 depict a 27-year-old woman who underwent bilateral reduction mammaplasty with acceptable early postoperative symmetry, then subsequently developed late stretch deformity of the lower poles (worse on the right side) resulting in noticeable asymmetry 2 years after her initial surgery.
Introduction
Reduction mammaplasty is currently the sixth most common surgical procedure performed on women by members of the American Society for Aesthetic Plastic Surgery. That same society reported 114,470 cases performed by its members in 2014. Breast reduction surgery has achieved one of the highest patient satisfaction rates among plastic surgery procedures with 93% to 97% of patients indicating that they would undergo the procedure again. The fact that this procedure enjoys tremendous success among patients despite reported complication rates of 53% is a testament to the efficacy of the operation in relieving the symptoms associated with macromastia and plastic surgeons becoming more adept at managing the more common postoperative problems associated with the surgery. Although complication rates reported in the literature range from 6% to 53%, it is most likely that with careful scrutiny of postoperative results the overall complication rate for this operation will approximate the 43% figure quoted from the analysis of the BRAVO (Breast Reduction Assessment: Value and Outcome) study. By far the most common complication reported in the literature is delayed wound healing followed by suture complications, hematoma, hypertrophic scars, nipple necrosis, fat necrosis, and seromas. Postoperative asymmetry is hardly ever mentioned in published series of breast reduction outcomes.
The possibility of postoperative breast asymmetry is always discussed with the patient as part of the preoperative informed consent process. Although it is currently the first complication listed in the breast reduction consent form created by the American Society of Plastic Surgeons, postoperative asymmetry requiring surgical revision is a rare event, occurring in less than 1% of cases. Currently, high-definition digital photography and standardized grids allow surgeons to critically assess their postoperative results ( Fig. 1 ). Under these conditions the surgeon frequently notices minor asymmetries in nipple position, volume, or shape of the breasts; however, asymmetries noticeable enough for the patient to request revisionary surgery are a rare occurrence. Only one case of postoperative asymmetry was reported by the BRAVO study consisting of 179 patients. A review of my last 267 breast reductions revealed only two revisions related to postsurgical asymmetry, one for nipple asymmetry and the other for unilateral bottoming out phenomenon resulting in a noticeable shape asymmetry. After reviewing my cases I was convinced that the low revision rate for asymmetry was mostly caused by personally performing all my preoperative markings and the major portions of the operation on both breasts, consisting of the tissue resection and shaping. However, at our local plastic surgery training program at the University of Miami, School of Medicine, it is common for two surgeons to work simultaneously during a breast reduction. As in most plastic surgery training programs, it may be a resident in training working on one of the breasts. Even under these circumstances, significant postoperative breast asymmetry requiring revision remains a rare occurrence. In the past 3 years and more than 200 cases, there have not been any operations performed at that institution solely for the purpose of correcting post-breast-reduction asymmetry. This favorable experience is in contrast with a recent study reporting a 15% rate of significant asymmetry following vertical reduction mammaplasty. Regardless of the technique used, appropriate preoperative markings and strict adherence to the markings during the surgery are still some of the most effective ways to prevent postmammaplasty asymmetry.
Breast asymmetry following reduction mammaplasty may involve the nipple-areolar complexes, differences in breast volume or shape, and/or location of the inframammary folds. Asymmetry that is noticeable early in the postoperative period is often the result of incorrect preoperative markings or poor surgical technique. Significant breast asymmetry may also occur years after a satisfactory initial result. Major weight fluctuations, pregnancy, or the long-term effects of aging can contribute to late asymmetry. Fig. 2 depict a 27-year-old woman who underwent bilateral reduction mammaplasty with acceptable early postoperative symmetry, then subsequently developed late stretch deformity of the lower poles (worse on the right side) resulting in noticeable asymmetry 2 years after her initial surgery.
Asymmetry of the nipple-areola complex
Malposition of the nipple-areola complex is a common occurrence following reduction mammaplasty. Most malpositions involve overelevation of the nipple-areola complex sometimes with asymmetry in relation to the contralateral side. A photometric study of 82 published reports of mastopexy and breast reduction reported a 41% incidence of nipple overelevation; however, none of the patients reviewed in the study had a nipple position below the level of maximum breast projection.
Significant nipple-areola malposition is one of the most distressing complications for the post-breast-reduction patient. Several techniques have been described for lowering a high-riding nipple-areola. However, the revision surgery comes with the tradeoff of placing a scar in the upper pole of the breast above the areola, which some patients are unwilling to accept. Most of these techniques involve transposition of local flaps or skin grafts. Some authors have reported lowering the nipple-areola complex by inserting tissue expanders through periareolar incisions into the subcutaneous plane of the infraclavicular region to recruit upper pole skin and avoid visible scars on the superior breast surface. In that series, the authors reported lowering the high-riding nipples by 2 cm to 6 cm without elastic tissue recoil following the expansion process. All the patients reported satisfaction with their nipple position after a 1- to 3-year follow-up period.
Recently Spear and coworkers proposed a classification system for the evaluation of the high-riding nipple and an algorithm for surgical correction. The classification is based on the location of the nipple in relation to the vertical height of the breast as described by Malluci and Branford. Nipple overelevation was defined as a location of less than 45% of the vertical breast height and three grades are described based on severity. Grade 1 (45%–35%) is considered mild, grade 2 (34%–25%) is considered moderate, and grade 3 (<25%) is considered severe. In addition, nipple malposition was also classified based on the relationship between the sternal notch, nipple-areola complex, and the inframammary fold. This further subclassified the nipple malposition into relative, absolute, or complex. Relative malposition is usually caused by a bottoming out deformity in which the nipple to inframammary fold distance is increased, making the nipple appear high on the breast; however, the sternal notch to nipple distance is normal. In absolute malpositions the sternal notch to nipple distance is short and complex malpositions involve an element of both. In a subsequent letter to the editor, Swanson questioned the reliability of this classification system on the basis that the anatomic landmarks used for the measurements are poorly defined and vary significantly from patient to patient. He proposes that the ideal nipple height should be defined as the apex or maximum projection point on the breast mound. However, Tebbets reports that the ideal nipple location takes into account the relative base width of the breast and suggests the following formula for determining nipple location: base width of breast × 0.67 = desired nipple to inframammary fold distance. Some authors have suggested that elevation of the inframammary fold, placement of high-riding implants, and elliptical resection of lower pole skin may be viable options in some select patients not willing to accept breast scars above the superior border of the nipple-areola complex.
A case of postreduction mammaplasty nipple asymmetry is presented. It involves a 58-year-old woman with macromastia and asymmetry of volume, shape, and nipple position ( Fig. 3 A, B ). The photographs ( Fig. 3 C, D) depict the early postoperative result with residual asymmetry of the nipples. The asymmetry became more apparent as time went on ( Fig. 3 E, F) and revision surgery was performed at the patient’s request. Results of the revision surgery are depicted ( Fig. 3 G, H).
