INTRODUCTION
Macromastia is a condition representing a
psychological, aesthetic and also somatic complaint
in the form of pain in the neck, back, shoulder and
bra strap groove, inframammary intertrigo, breathing
and sleeping problems and upper extremities
numbness [1-3]. Breast reduction for releiving of
331
those symptoms is one of the most common aesthetic
surgeries done in US [4]. The currently
available methods for breast reconstruction are
liposuction and pedicle techniques [5]. Inferior
pedicle which was originally described by Riebeiro,
Courtiss, and Goldwyn and Robbins had been
perhaps the most commonly performed technique
in United States [6-8].
Being a surgical procedure the inferior pedicle
technique is not without complications [4,9,10].
Breast liposuction was first practiced in 1991, it
has become a promising method for breast reduction
with low morbidities [11].
This study aimed at subjective and objective
comparison of liposuction breast reduction versus
inferior pedicle mammoplasty being the most currently
performed methods for breast reduction.
PATIENTS AND METHODS
From January 2015 to November 2017 random
sample of fifty two patients having macromastia
were included in this study. We exclude patients
more than 30 years old, those with poor skin quality
and those with family history of cancer breast.
This study was conducted in plastic surgery unit,
general surgery department, Zagazig University,
Egypt. Patient's details are summarized in Table
(1). Twenty six patients representing odd numbers
were operated up on by liposuction alone and
described as group A. Twenty six patients represented
the even numbers were operated by inferior
pedicle reduction and described as group B. All
patients were consented to the procedure after it
has been approved by the university committee.
All preoperative routine investigations including
mammography were done for all patients. Patient's
records were interpreted with regard to patient's
ages, body mass indices (MBI), operative times,
reduction in sizes (which is known from reduction
in sternal notch to nipple distance), amount excised
in grams (in liposuction 100ml aspirated fat is
considered equal to 80 grams), relief of preoperative
complaint, hospital stays and postoperative complications.
Patient's satisfaction was assessed according
to Elder et al., 2005 scoring system [12].
All data were presented and statistically analyzed
using two sample t-test of SPSS version 16.
Group A surgical technique (Figs. 1-4): In this
study we used the technique of Moskovitz and
Baxt, 2004 [13] with modifications of using general
anaesthesia for all cases and using cannulas numbers
3.7 and 4.6 only. We also used two stabs (one
lateral end of inframammary fold while the other
just above the breast tissue in the lateral axillary
fold) to infiltrate the tumescent solution and to
aspirate the fat which were then closed by inverted
dermal sutures using poly-glycolic acid 5/0. Post
operatively, all patients were dressed in elastic
garments which continued for 2 months.
Group B surgical technique (Figs. 4-8): The
same as described by Mandrekas et al., 1996 [14]
with some modifications of; areola size was only
4cm and the suction drains were kept till the amount
becomes less than 25ml serous fluid over 24 hours.
Antibiotics were given during induction of anesthesia.
Thrombo-prophylaxis was started 12 hours
before surgery and then continued for 2 days postsurgery.
Small triangles of 0.5cm height were left
at the center point of the pedicle which were then
either kept or removed according to tension at T
shaped junction line during closure.
RESULTS
All patients of both groups were followed up
with average 12 months (range from 6 to 33
months). Table (1) and Fig. (9) illustrate the differences
in the age, BMI, operative time, hospital
stay, post-operative reduction in size, amount
excised or suctioned in grams and relieve of
preoperative patient's complain between both
groups. Mammography was done at 6 months then
after one year in case of liposuction revealed dense
glandular element and or scarring in dermal areas
which could easily distinguish from malignancy.
The mean operative time, hospital stay was significantly
low in group A than group B. The mean
reduction in breast size manifested by sternal notch
to nipple distance and the average amount of excised
or suctioned tissue was significantly high in
group B than group A (Table 1 and Fig 9).
Most patients of both groups experienced subjective
relieve of their preoperative complaint.
332 Vol. 42, No. 2 / Liposuction Reduction Alone Versus Inferior Pedicle Mammoplasty
The overall complication rate was significantly
higher in group B than group A (p<0.05). The
percentage of post-operative complication rates
(haematoma, loss of nipple and areola sensation,
wound complications) was higher in group B than
group A. Nipple necrosis, fat necrosis and seromas
were comparable in both groups (Table 2).
Patients satisfaction was higher in group A
than group B (92.3% versus 80.7%). The most
prevalent items of satisfaction are the symmetry
and the sensation of nipple and areola while the
most prevalent item of dissatisfaction was the
post-operative scar. Surprisingly in this study the
reduction in size was not a leading item for
patient's satisfaction (Table 3, Fig. 10).
Table (2): Postoperative complications.
p*
0.32
0.56
0.54
0.56
0.07
0.07
0.01*
Group B
(num/%)
0/26
1/26 (3.8)
1/26 (3.8)
1/26 (3.8)
0/26
0/26
3/26 (11.6)
Group A
(num/%)
1/26 (3.8)
2/26 (7.7)
1/26 (3.8)
2/26 (7.7)
3/26 (11.6)
3/26 (11.6)
12/26 (46.2)
Haematoma
Seroma
Fat necrosis
Nipple necrosis
Loss of nipple and
areola sensation
Wound complications
Total
Item
Table (3): Patient's satisfaction after 6 months.
Group B
17 (65.3%)
7 (27%)
2 (7.7%)
Group A
13 (50%)
8 (30.7%)
5 (19.3%)
Very satisfied
Satisfied
Unsatisfied
Table (1): Demographics, operative time, size, excised tissues,
hospital stay and relieve of preoperative complaints.
p*
0.2
0.3
0.000*
0.000*
0.000*
0.000*
0.39
Group A
23.69±11.4
28
27.58±1.7
93.65± 17.2
14.5±1.3
639±201
1.1±0.4
92±21
Group B
26±9.9
24
28.31±2
156±17.15
12.75±2.14
1265±447
5.69±1.2
85±35
Age
Single unmarried
BMI
Operative time
(minutes)
Post-operative Sternal
notch to nipple (cm)
Amount suctioned or
excised (gm)
Hospital stay (days)
Relieve of preoperative
complaint
Egypt, J. Plast. Reconstr. Surg., July 2018 333
Fig. (3): lipoaspirate (case 2).
Fig. (1A): Pre-liposuction of breast (case 1) with measurements.
Fig. (4): Post-liposuction photo (case 2).
Fig. (2): Pre-liposuction photo (case 2).
Fig. (1B): Post-liposuction of breast (case 1) with measurements.
Fig. (5): Pre-op. photo (case 3).
DISCUSSION
Macromastia is not only a psychological and
aesthetic troublesome but also somatic complaint
for women [1-3].
Currently available methods for breast reduction
are liposuction and/or surgical pedicle techniques
334 Vol. 42, No. 2 / Liposuction Reduction Alone Versus Inferior Pedicle Mammoplasty
[5]. All methods are aimed to alleviate the symptoms
and to preserve normal breast shape, contour
and sensible nipple and areola without neglecting
the oncological aspect [15-16].
This prospective study was conducted on 52
patients who divided randomly into two equal
groups aiming to compare the most commonly
performed procedures for breast reduction.
The mean operative time in liposuction breast
reduction alone (93.65±17.2min) was statistically
shorter than the inferior pedicle group (156±
17.15min) which means shorter anesthesia time
with fewer hazards for the patient.
Other series reported an average operative time
of 57min (40-90min) and 71min (45-130min) for
liposuction reduction respectively [5-17] which is
lower than reported by our series due to the learning
curve which was low early then improved afterwards
while that for inferior pedicle is 120min
(125-279min and 151.3min±58.9 which nearly
similar to our results [13,18].
Fig. (6): Post-op. photo (case 3). Fig. (7): Pre-op. photo (case 4).
Fig. (9): Demographics, operative time, size, excised tissues,
hospital stay and relieve of preoperative complaints.
160
140
120
100
80
60
40
20
0
Relieve
of preoperative
complaint
Hospital
stay
BMI Operative
time
Reduction
in sternal
notch to
nipple....
Age
Group B Group A
Fig. (10): Patient's satisfaction after 6 months.
70
60
50
40
30
20
10
0
Satisfied
Group A Group B
Very satisfied Unsatisfied
Fig. (8): Post-op. photo (case 4).
Egypt, J. Plast. Reconstr. Surg., July 2018 335
Both techniques were noted to be comparable
in relieve of patient's preoperative somatic complaint
and this also reported by multiple previous
series [5,19-22].
In this study the mean volume loss per breast
after liposuction reduction is significantly lower
than the loss by inferior pedicle (639.2gm versus
1265.7gm). The reduction in size as noted by the
mean reduction in sternal notch to nipple distance
is also significantly low in liposuction reduction
group (4.5cm versus 12.75cm).
In a study done by Moskovitz et al., 2007 on
liposuction reduction the mean reduction in sternal
notch to nipple distance was 4cm and average
volume loss was 1 liter [19]. Another study done
by Mellul et al., 2006 on liposuction reduction the
average volume loss was 712.96cc which equals
570 gm and an average reduction in sternal notch
to nipple distance was 2.59cm [11]. Other studies
reported reduction of 542 gm and 850gm and mean
reduction of sternal notch to nipple distance of
6cm [23,24]. So results of our study regarding
reduction of volume and sternal notch to nipple
distance in liposuction group fail in between other
series.
Other studies on inferior pedicle mammoplasty
reported mean volume losses of 982gm (average
185 to 1930gm), 525gm (average 400 to 700gm)
and 1.1kg (average 440 to 2500gm) [17,25,26] which
are less than reported in our study and this may
explained by large sizes of breasts seen in our
community.
Nipple and areola sensation was not affected
in liposuction reduction group which was also
noticed by other series [13,16,19.21].
Three cases (11.6%) developed loss of their
sensation in inferior pedicle group which is similar
to that reported by other series 13% and 10%
[27,283].
The overall complication rate was significantly
lower in liposuction group than inferior pedicle
group (11.6% versus 46.2%).
Complication rate of liposuction group fail in
the center of that reported by other series; 1.7%,
20%, 33% and 34% [5,22,29,30].
The complication rate of inferior pedicle group
is nearly similar to that reported in other series
47% and 50% [4,31] with the most common item
is the wound complications.
Patient's satisfaction by liposuction reduction
is higher than in inferior pedicle especialy in
unmarried single female who seek for scarless
reduction (92.3% versus 80% of patients whose
ranged from satisfied to very satisfy).
Our results regarding patient's satisfaction by
liposuction breast reduction are nearly equal to
study done by Moskovitz et al., 2004 who reported
91% of patients ranged from very satisfied to
satisfied while 9% was unsatisfied and Mellul et
al., 2006 who reported 93% satisfaction rate [5,11].
In a study done by Makboul et al., 2017 on
inferior pedicle mammoplasty 73.3% of patients
was ranged from very satisfied to satisfied while
27% was unsatisfied and Ramon et al., 2000 reported
75% of patients was satisfied, while 25%
was unsatisfied which nearly similar to our results
[32,33].
In this study the most common item regarding
patient's satisfaction is relieve of preoperative
somatic complaint while that for dissatisfaction is
the postoperative scar. Many series reported that
the relieve of preoperative complaint overwhelms
the cosmetic concerns and the postoperative scaring
is the most frequent cause of dissatisfaction
[25,31,34]. Others reported that reduction in size is
the leading item of patient's satisfaction which
was not the case in our study [5,11].
Conclusion:
A high rate of complications was observed in
inferior pedicle mammoplasty. Regarding patient's
satisfaction and based on our finding that instead
of liposuction reduction alone did not achieve a
great reduction in size and volume but patients in
this group presenting higher satisfaction rate than
the other group due to absence of visible scars
especially in unmarried female with good skin
quality.
Based on the finding in this study liposuction
breast reduction alone is recommended as first
option for breast reduction of medium sized breasts
with good skin quality. The inferior pedicle technique
might be chosen for reduction of large to
giant breasts or for patients who are unsatesfied
with breast liposuction.
