Recurrent mammary hyperplasia

Reduction mammaplasty is now one of the most commonly performed operations in plastic surgery. Patient satisfaction with breast reduction is high regardless of pedicle choice or incision pattern, a fact that has now been well elucidated by multiple outcome studies [1, 2]. In addition, the operation carries a relatively low incidence of complications. Prevention and treatment of some of the most devastating complications such as nipple loss has also been well described [2-4]. One of the least frequent complications of breast reduction surgery is recurrent hyperplasia of the breast. This diagnosis presents many unique challenges to both the patient and the surgeon and heavy emphasis must therefore be placed on preoperative counseling [5, 6]. Symptomatic hypermastia, the condition of breast enlargement which most frequently leads the patient to reduction surgery, is characterized by a group of symptoms stemming from the excess weight and muscle strain of enlarged breasts. Common symptoms presented include neck, back, and shoulder pain, as well as shoulder notching and intertriginous rashes. Many of these patients are obese and may not experience resolution of symptoms such as back and neck pain following breast reduction. Despite this, patient satisfaction remains well over 80% among reduction mammaplasty patients [1, 2, 7]. Occasionally, patients present with postoperative concerns that are aesthetic in nature and are caused by asymmetry, scarring, and/or shape of the breast mound. Inadequate excision and recurrent hypermastia are more complex concerns, which require careful evaluation and treatment. Analysis of both the presented deformity and the original surgical approach is critical in determining an operative plan [8]. A woman may be disappointed with her postoperative result because of scarring, asymmetry, and oddshaped or boxy breasts; rarely is the disappointment due to inadequate excision [7]. Loss of nipple sensation and inability to breast-feed are infrequent complaints because patients oft en expect this postoperatively if properly counseled. Informed consent with proper communication preoperatively usually prevents unrealistic expectations. Recurrence should be mentioned in preoperative discussions, but is primarily a risk in patients with juvenile hypertrophy [9]. Long-term scars are one of the tradeoff s of reduction mammaplasty [10]. Although various techniques have been designed to minimize scarring, complete elimination of scars is clearly impossible. On follow-up, physical examination is important to ensure that incisions are healing appropriately and patients are counseled on realistic expectations for ultimate scar maturation. Postoperative massage and silicone pressure sheeting can be encouraged, and time is allowed for scar maturation. Occasionally, scar revision is undertaken aft er the patient is counseled that the scar may not improve even with surgical intervention. The psychological impact of poor scarring should not be underestimated. Breast asymmetry is a norm and should be pointed out preoperatively to the patient. If only a slight undesirable asymmetry exists, liposuction can be performed with good results [10]. If a larger discrepancy exists, surgical revision can be considered. An appropriate interval usually a minimum of 6 months for swelling to resolve and wound maturation to occur should be allowed before revision is considered. Preoperative expectations clearly influence a patient s satisfaction with shape. Patients need to be counseled preoperatively that the initial result is designed to both allow for and minimize the inevitable "bottoming out" that occurs over time [11]. The goal of breast reduction should not be to create a virginal-appearing breast but rather a mature, slightly pendulous breast that will persist proportional to the patient s build [12, 13]. Inadequate excision is a rare complaint and must be distinguished from recurrent hypertrophy as an indication for repeat breast reduction [2]. Preoperative expectations should be openly discussed. This is imperative to avoid misunderstandings and disappointments between surgeon and patient. Regnault and Daniel [14] described the amount of excised tissue needed to decrease breast size in various chest circumferences (Table 85.1). Acutely, hematomas or seromas may be the culprit for size discrepancies and likely need drainage. In addition, infection and swelling need to be considered. Operative re-excision should be performed if there is a gross discrepancy in size immediately postoperatively. In this case, reopening of incisions should allow dissection along previous planes without compromising the known pedicles.