BREAST REDUCTION WITH LIPOSUCTION, DANIEL LANZER, M.D.
INTERNATIONAL JOURNAL OF COSMETIC SURGERY and AESTHETIC DERMATOLOGY
Volume 4, Number 3, 2002 © Mary Ann Liebert, Inc.

ABSTRACT

Hypertrophic large breasts are a common problem to women of all ages. This article discusses the results of using tumescent liposuction alone for breast reduction on 250 patients.

INTRODUCTION

HYPERTROPHIC LARGE BREASTS are a common problem to women of all ages. Complaints include back and shoulder pain, disturbance of posture, and indenting of bra straps all related to the excessive weight from breast hypertrophy. Other problems include persistent submammary maceration and psychological disturbances due to the prominence of this area. The traditional method of breast reduction has been surgical excision mammoplasty. It involves excision of breast tissue and skin with a localized flap. The procedure is complex and extensive with significant risks that include unsightly scars, keloid, necrosis, permanent numbness, prolonged postoperative recovery, blood loss, reduction in the ability to breastfeed, and radiographic changes on mammography that
may cause confusion with breast cancer. Klein(1) and Dryden(2) reported early studies on the method of tumescent liposuction alone for breast reduction. Liposuction is comparatively rapid, less invasive, essentially nonscarring, and has fewer risks. The initial work was on selected individuals and more extensive studies were necessary to ascertain if the results were reproducible, if risks were likely to occur, and to determine guidelines for patient assessment.

METHOD

A total of 250 patients underwent breast reduction by tumescent liposuction alone. All patients underwent routine preliposuction work-up, which included blood tests and administration of preoperative antibiotics and antiseptics. A personal and family history of previous breast cancer or cysts was taken. Patients were asked why they wanted reduction, what their current bra size was, and what they would ideally like it to be. Patients were asked if they had breastfed in the past and if they had a significant desire to be able to breastfeed in the future. No patient had a previous history of breast cancer. All patients with a family history of breast cancer were referred to a breast cancer surgeon for assessment and long-term follow-up. Preoperative assessment included a visual examination for assessment of shape, extent of droopiness, stretch marks, skin elasticity, and for asymmetry. Physical examination of the breast was carried out both to exclude any obvious breast lumps and to assess the nature of the breasts. Breasts were graded from 1 to 10:10 corresponded to a soft, spongy texture as one would expect if the breast tissue was made up of fat primarily; 1 described hard, firm breasts.Preoperative mammography and ultrasound were performed on all patients. Of the total, 248 patients had general anesthesia in an accredited surgical setting, 1 had sedation, and 1 local anesthesia. The breasts were marked into four or six sections with attention paid to the apex of the breast, for signs of asymmetry, and the axillary tail if relevant. Approximately five 1–2 mm nicks were made at the base of the breasts and three smaller nicks midway up the breast (excluding the medial upper regions in order to avoid any signs of surgery in this area). Both breasts were filled simultaneously with Klein tumescent fluid using 20 gauge needles. The lidocaine level was diluted to 125 g/1000 ml when performed under general anesthetic. Between 1 and 2 L were infiltrated in each breast until maximum tension was produced. Suction was via a 14 gauge Klein microcannula of the capastrano variety. Two surgeons simultaneously operated from each side of the table, mirroring each move. Fat was sequentially extracted from superficial, midbody, and the base of the breasts. Suction was performed from all different directions, with the angle of suction varied to allow maximum and even fat removal. In large and very dense breasts, 12 gauge needles were then used. Patients wore a compression chest binder continuously for 2 weeks postoperatively and for 2 weeks intermittently. Attention was paid to keeping the nipples elevated during this phase.

RESULTS

Virtually all patients have been pleased with the results of surgery (Table 1). In approximately one-third of patients 200–400 ml fat was removed from each breast; in one-third 400–700 ml was removed; and in the other one-third more than 700 ml was removed. The maximum volume removed was 2.7 L fat from each side. Breasts vary between patients and in some cases 80–90% of the breast mass is made up of fat, which could be removed by liposuction alone. There were no complaints of loose skin and this included patients who were cup size G with large sagging breasts. Many patients commented on a reduction in stretch marks. In approximately 50% the axillary tail was treated simultaneously, and in approximately 20% liposuction was performed elsewhere such as on the abdomen. Approximately 30% of patients had incidental differences between breast sides documented preoperatively and more fat was removed on the largest side. Five patients underwent liposuction of one breast only to correct asymmetry. The main reason for having surgery was to alleviate pain and discomfort, followed by amelioration of “self-consciousness” about the breasts. All patients who had the procedure for amelioration of discomfort noted a significant, often instantaneous, improvement in their symptoms. Most patients returned to work in 2 days.

COMPLICATIONS

Minor complications included tenderness and deep bruising in all patients. There were no cases of loose skin or irregular shape. Major complications included pain in 1/250 patients.
There were no reports of permanent sensation loss, scars, necrosis, infection, “empty sack,” or prolonged recovery time. All patients were pleased with the amount of nipple and breast elevation (Fig. 1–4). Elevation varied between 3 and 15 cm. Many patients wanted “as much” reduction as possible, while others just wanted a reduction of one size. A common reduction was from a DD or E to a C/D cup size. There is a definite lack of uniformity about sizes given by patients and their results. There were no significant complications. All patients experienced deep bruising, which
lasted up to 10 months in some patients. All patients noted initial tenderness but there have been no permanent sensation changes of the nipple. Two patients have commented that they have had better sensation since surgery. There have been no cases of scarring. One patient complained of significant early tenderness that gradually improved but was still present 6 months after surgery. There have been no cases of clinical significant microcalcification or scars appearing radiographically on mammograms in the 6 months after surgery. No patients have tried breastfeeding
since the surgery. In theory there is less destruction to the breasts with liposuction and therefore feeding may be possible. Suction immediately under the nipple was avoided in patients who expressed strong desire to breastfeed later in life.

CONCLUSIONS

Breast reduction via liposuction is consistently reproducible. The procedure is rapid and comparatively simple. Since breast liposuction is technically more difficult than liposuction in other areas, and since an irregular suction would be significant, I would suggest that surgeons only perform this procedure when they have extensive liposuction experience in other areas of the body. In most cases this procedure would be better defined as a medical operation “for pain” rather than true cosmetic surgery. As a result, patients are very appreciative and happy with the removal of symptoms and the weight-bearing difficulties caused by large breasts. The success of this procedure compared with previous breast liposuction attempts relates to the three main technical issues: the tumescent fluid softens and separates the fat; endoscopy during the procedure demonstrates fat removal yet leaves the breast fibrous bands intact; and microcannulae allow maximum fat reduction with the least trauma and hematoma formation. Superficial liposuction of the underlying skin over the entire breast surface enhances the contraction of the nipple. Virtually all patients were pleased with the procedure, the initial postoperative recovery, and their results. It is too early to report longterm results; however, there is no reason to suspect that they would change. Many patients comment that their breasts did not reduce in size with weight loss and most likely these patients will not experience a recurrence even if they put on weight. As breasts change under hormonal variations, no guarantees of permanence can be given. Breastfeeding after this procedure has not been investigated and will require further follow-up. The most significant long-term issue is the effect of liposuction on breast cancer. Mammography does not pick up every breast cancer, particularly cancer in situ. It is likely that an older patient will at some time have liposuction that theoretically could seed the cancer. Should a cancer develop later, it may be possible that its natural course will be altered. Conversely, a patient with a smaller breast may detect a cancer at an earlier stage by palpation. Further long-term investigation of this in our patients will be appropriate.

ACKNOWLEDGMENT

The author thanks breast surgeon Dr. Suzanne Neil for advice and Dr. Herbert L. Mavevich for radiological guidance.

REFERENCES

1. Klein, J.A.: Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction. St. Louis: CV Mosby, 2000.
2. Dr. Dryden, American Academy of Cosmetic Surgery Conference, Florida, February 2000.

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