Advances in Liposuction for Breast Reduction
Various procedures have been used for breast reduction. However, traditional techniques have led to significant breast scarring. These concerns have led to the emerging use of liposuction of the breast either as a primary or complimentary modality in order to achieve mild to moderate reduction in breast size with minimal scarring.
Liposuction has been used as an adjunctive technique for breast reduction in addition to more traditional methods for over two decades.1 In 1985, Teimourian et al introduced the concept of liposuction of the breast as an adjunct to breast mastopexy or reduction for the purposes of volume reduction of the female breast.2 In 1991, Matarasso and Courtiss introduced the use of liposuction alone as a breast reduction technique, but this technique was only applicable to women with well-placed nipple-areola complexes and predominately fatty breasts.3 Two years later, Courtiss stated that women with breast ptosis, large areola, and firm parenchyma could also be successfully treated by liposuction alone.4 He noted a rise in the nipple-areola complex concomitantly with a decrease in breast mass. In 2001, Gray updated his experience with 204 women undergoing liposuction breast reduction,5 and in 2004, Moskovitz, et al reported the first outcome study for liposuction as a primary method of breast reduction surgery.6
In the report by Moskovitz, Muskin, and Baxt,6 questionnaires were sent to 117 patients who had undergone liposuction breast reduction surgery during a 4-year period. Seventy-eight questionnaires were returned (67% response rate). Complaints such as neck and back pain, shoulder ruts, and intertrigo were improved or eliminated in the vast majority of patients. Women returned to work in 5 days on average and resumed full exercise in 2 weeks. Eighty percent of patients were either very or completely satisfied with their outcomes, 87% said they would choose the liposuction method again, and 92% said they would recommend the liposuction method to a friend.
• Of utmost importance is ordering a pre-operative mammogram to screen for breast cancer and to assess breast fat-parenchyma content.
• We routinely employ intravenous conscious sedation for most of our patients undergoing cosmetic surgical procedures, utilizing a certified ambulatory surgical suite.
• To ensure symmetrical elevation to counteract the natural gravitational pulling of breast tissue, it is paramount to have the patient marked in an upright position.
• Access incisions are made in the periareolar, inframmary, or axillary folds.
• We use 3-mm to 4-mm cannulas attached to a 60-ml syringe, and the dissection is carried out in a spokewheel pattern.
• The patient is periodically elevated to a semi-sitting position to evaluate symmetry and desired outcome and the cannula port is maintained in a downward direction.
• A single absorbable suture is used to close surgical wounds.
• The patient wears a vest garment for approximately 4 weeks following the procedure.
• Most patients return to work within a few days.
• A post-operative mammogram 6 months after the procedure is recommended.
Liposuction versus Traditional techniques
Traditional methods of breast reduction for large breasts are all associated with extensive procedures and significant breast scarring.
The efficacy of liposuction for breast reduction has been well established,7 and it compares to traditional open techniques for certain patients. In a recent retrospective chart and imaging review of 14 female patients who underwent breast reduction by liposuction, Mellui et al7 reported a patient satisfaction rate of 93%. Nipple elevation was measured to be at a mean of 2.57 cm compared to preoperative values. Older patients (>60 years of age) were noted to have a significantly larger nipple elevation (3.16 cm vs. 1.79 cm).
Changes in volume ranged between 695.57mL and 712.71 mL per breast. Radiographic changes induced by liposuction were not statistically different from those found in traditional reduction techniques.
In addition, patients with a body mass index of less than 25.0 had a greater mean volume reduction in breast size 6 months post-liposuction versus patients with a body mass index of greater than 30.0 when compared via the dip test.
Breast Size and Volume
Depending on the breast volume, different surgical techniques may be indicated. Our experience has been that liposuction can achieve mild to moderate breast reduction with minimal scarring. (See Figures 1 and 2) This reduction ranges from 0.5 to 1.5 cup sizes. On the other hand, moderate to extremely large breasts may be best managed by traditional procedures.
There is a subset of patients mainly concerned with excess breast size and weight who are seeking surgery to ameliorate neck and back pain. Liposuction as a sole modality for this subset of patients has proven to be effective, with a lower rate of complications, a higher level of patient satisfaction, a significant return to normal activities, and with noticeable savings in operating room costs. It was once believed that liposuction breast reduction could be successfully performed only in fatty breasts. Although suction removes fat more easily than parenchyma, liposuction can reduce the size of firm breasts that have a major parenchymal component by using the right technique and adequate cannulas. The average breast reduction in patients with firm breasts ranges from 0.5 to 1 cup size.
This modality also shows promise for African-American patients given the known scarring difficulties that darker-skinned patients can encounter with traditional breast reduction surgery. In a prospective trial by Moskovitz et al,8 17 African-American women showed a significant decrease in breast-related symptoms, a significant decrease in pain, and significant improvement in overall health perception after undergoing liposuction breast reduction.
Complications of breast reduction include infection, hematoma, seroma, dehiscence, fat necrosis, and skin loss.9 Moreover, patients may complain of poor shape, extensive or painful scars, numbness, and inability to breast feed.5
However, while complication rates from traditional breast reduction surgery range from 29%10 to 50%,9 there is an extremely low complication rate with liposuction breast reduction. In a review by Sadove11 of patients treated with liposuction to achieve breast reduction, he did note that some patients may experience temporary inversion of the nipple during the postoperative period.
In addition, Sadove11 also compared pre- and post-treatment mammograms of patients. Mammograms demonstrated increased glandular density and were essentially without calcification. They proved significantly easier to interpret than mammograms performed after traditional reduction.3,12 We routinely recommend pre- and post-treatment mammograms for patients undergoing liposuction of the breasts.
Ideal Method for the Right Patient
Liposuction for breast reduction has the advantages of little downtime, minimal scarring and a low rate of complications. In conclusion, for a select subset of patients, liposuction of the breast can achieve mild to moderate reduction in breast size with minimal scarring and satis factory cosmesis.