LIPOSUCTION TEXTBOOK

Chapter 38:
Female Breasts

Tumescent liposuction for reduction mammoplasty permits significant female breast reduction with virtually no scarring. With the tumescent technique for liposuction totally by local anesthesia, patients have minimal postoperative pain, rapid postoperative recovery, and quick return to normal activities. The liposuction uses special breast microcannulas, and postoperative care requires trimodal compression garments.

Breast Hypertrophy and REduction

Excessively large breasts are undesirable for the following reasons:

1. Female breast hypertrophy causes pain and suffering, physical impairment, and psychologic problems.
2. Athletic activity is significantly limited.
3. Changes in posture to compensate for the weight of excessively large breasts can lead to chronic degenerative changes and pain in the neck, shoulder, and back.
4. Chronic pressure from impinging bra straps causes permanent indentations on the shoulders. Large breasts predispose to inframammary intertrigo.
5. The woman may view her large breasts as cosmetically undesirable.
6. Finding a bra that fits and is comfortable may be impossible, and clothing does not fit well.

Excision

Surgical breast reduction by excision has been the only solution for women who have excessively large breasts. Excisional breast reduction surgery has various risks and postoperative complications (Box 38-1). The routine reliance on general anesthesia and prolonged postoperative pain and recovery make excisional breast reduction mammoplasty a less-than-ideal surgical procedure.

Theoretically, unweighting the female breast by removing an equal proportion of the fat volume from each cubic centimeter of breast tissue has the following two effects (Figure 38-1):

1. The breast is reduced in size in direct proportion to the fraction of fat removed.
2. The elastic suspensory Cooper’s ligaments are more effective in elevating the breast, giving the appearance of a breast lift.

The application of tumescent liposuction to the female breast can elevate the nipple and areola, elevate the inferior breast margin, and reduce breast size. The surgery is accomplished totally by local anesthesia. Only 12 to 18 adits are used, each 1.0 mm in diameter and all of which become virtually invisible. Patients can return to work in 2 to 4 days.

Liposuction

Tumescent liposuction of the female breast totally by local anesthesia has proved to be successful. The technique requires specially designed 16-gauge (1.2-mm inside diameter [ID]) and 14-gauge (1.6-mm ID) breast microcannulas and multiple 1.0-mm adits that are not closed with suture. Postoperative recovery and healing are rapid. Within weeks the breasts appear normal and feel normal to routine palpation.

All patients treated have been gratified by the results. Comparison of preoperative and 6-month postoperative mammograms did not reveal new calcifications. Liposuction of the female breast is a relatively new procedure, and questions remain to be answered.

Breast reduction by liposuction under general anesthesia has been reported.¹ The clinical study described 12 patients and a high degree of patient satisfaction. The procedure reduced the ptosis of the breasts and the size of the areolae. The cannulas were large (2.4-mm to 5-mm ID), however, and postoperative edema and firmness persisted for up to 1 year.

Breast reduction by liposuction with 2 to 3 L of fluid infiltrated per breast has been reported more recently.² The surgeon used general anesthesia, relatively large (3-mm and 4-mm) cannulas, and only two incisions per breast.

Results and Candidates. Microcannular tumescent liposuction can remove 30% to 50% of the breast volume with minimal risk of postoperative morbidity. As much as 60% of volume can be removed from breasts with a high percentage of fat. The maximum volume of aspirate and degree of reduction should be discussed with the patient and documented before surgery. The typical patient can return to work and normal social activity 2 to 3 days after surgery. The technique appears to be most appropriate for breasts of moderately large volume (e.g., 600 to 1600 ml), but the limits for volume reduction by liposuction have yet to be defined.

Tumescent breast reduction is only appropriate for a select subset of women seeking reduction mammoplasty. The current technique might not be appropriate for patients who need considerably more than a 50% reduction or for those whose breasts are pendulous or largely devoid of fat. For the appropriate patient, however, the results of tumescent liposuction can be extremely gratifying. For example, evidence of adits disappears within a few weeks or months (Figure 38-2).

A modest but pleasing elevation of breast position relative to the costal margin is the result of the following (Figure 38-3):

1. Reduced breast weight
2. Postsurgical contraction of the collagenous fibers within the subcutaneous fat
3. Elastic properties of Cooper’s suspensory ligaments

Realistic Goals

Simplicity, symmetry, and consistency describe the surgical approach that is most likely to produce results that satisfy the patient. The goal of tumescent liposuction of the female breast is the uniform removal of tissue from the breast with no scars. Conceptually, this is achieved by reducing the volume of each cubic centimeter of breast tissue by an equal amount, such as 40% to 50%. Fundamentally, the surgeon is attempting to create a smaller version of the preexisting breast.

This simple approach produces the most desirable results as follows:

1. The breast weighs less.
2. The natural elasticity of the skin and breast tissues elevates the breast and the relative position of the nipple.
3. The breasts are better proportioned, better positioned, more symmetric, and more comfortable.
4. The postoperative recovery is rapid and relatively pain free, with no unsightly scars.

Symmetry in shape and size is an important goal, in addition to achieving the desired reduction in breast volume. The procedure should create two breasts that are similar in size and shape.

Anatomic Considerations

The female breasts that are candidates for reduction mammoplasty are composed of a significant proportion of fat. The glandular breast tissue is generally located nearest the nipple. When a patient is supine, most of the glandular tissue is located within the center of the breast deep to the nipple. The dense fibrous tissues of the female breast are not easily infiltrated or aspirated. Peripheral portions of the breast are more fatty (Figure 38-4).

Sensory innervation of the nipple-areolar complex is derived from the anterior branch of the fourth intercostal nerve. Surgical impairment of nipple sensibility correlates with damage to distinct neuroanatomic nerve endings and conducting fibers.³

The HK Brest microcannulas are specifically designed for breast liposuction. The extra small holes of the microcannula allow selective removal of fat with little collateral injury to other tissue. Risk of nerve injury is much less with microcannulas than with large cannulas or with scalpels and cutting cautery. Any surgery risks nerve injury, however, and thus the liposuction surgeon should be aware of the anatomic path of the anterior branch of the fourth intercostal nerve, as follows:

1. The fourth intercostal nerve traverses the serratus anterior muscle at the fourth intercostal space at the midaxillary line.
2. It then travels beneath the deep fascia of the serratus.
3. It crosses over the lateral margin of the pectoralis major muscle and continues tangentially over this muscle until it passes beneath the mammary gland.
4. The nerve enters beneath the breast at the inferolateral margin of the fatty tissue, at the 4 o’clock position on base of left breast and 8 o’clock position on base of right breast.
5. It travels about 2 cm (¾ inch) beneath the breast tissue.
6. It then courses anteriorly through the breast parenchyma toward the nipple-areolar complex along a variable path.
7. Midway through the breast the nerve begins to divide into several branches, usually five, which then innervate separate but overlapping areas of the nipple-areolar complex.

The relative distribution of fat within the female breast’s central portion is about 67%, in the lateral portion about 87%, and in the preaxillary area about 84%.^3a

Preoperative Evaluation

Preoperatively the volume of each breast is measured by a water-displacement method. Before measuring breast volume, the breast’s proximal superior margin is symmetrically outlined to ensure equal depth of immersion. The breast is immersed in a beaker filled to the brim with warm water. After removing the breast from the beaker, the volume of water needed to refill the beaker to its brim is recorded.

It is important that the depth of breast immersion be consistent and equal for both left and right sides. The average of at least two measurements provides a good estimate of each breast’s volume (Figure 38-5).

Accurate preoperative breast volume measurement is necessary for planning the appropriate amount of tissue to be removed from each breast. Significant asymmetry between the two breasts can be corrected by removing an appropriate extra amount of supranatant fat from the larger breast.

Also, preoperative breast measurements allow the surgeon to estimate the volume of tumescent anesthetic solution that will be infiltrated. The volume of solution required for complete tumescent anesthesia is about equal to the preoperative volume of that breast. In other words, the tumescent breast will be approximately twice is preinfiltration volume (Figure 38-6).

Tumescent mammoplasty permits accurate breast reduction of a specified volume by measuring the amount of tissue aspirated from each breast. Preoperative volumetric measurement has the following advantages:

1. Quantification of the degree of asymmetry between breasts
2. Precision when determining the amount of tissue to be removed
3. Calculation of the volume to be removed from each breast to achieve both symmetry and reduction

For example, a woman’s left and right breasts measure 1000 and 1200 ml, respectively. She wants correction of asymmetry and 40% breast reduction. By removing 300 ml of supranatant fat from the left breast (1000 – 300 = 700) and 500 ml from the right breast (1200 – 500 = 700), postoperatively the breasts are approximately equal in size. The left breast is reduced by 30% (300/1000) and the right breast by about 42% (500/1200).

Anesthetic Infiltration

The preferred formulation of the tumescent anesthetic solution is approximately as follows:

Lidocaine 1500 mg

Epinephrine 1.50 mg

Sodium bicarbonate 10 mEq

In 1 L of 0.9% isotonic saline

The goals of tumescent infiltration of the female breast are as follows:

1. Produce complete local anesthesia.
2. Achieve optimal hemostasis.
3. Preserve the breast’s relative size and shape.

In other words, infiltrate completely and inflate uniformly. Conceptually, this is achieved by injecting an equal and sufficient volume of anesthetic solution into each cubic centimeter of breast tissue so as to achieve complete local anesthesia. Precision and completeness are more important than speed. Fundamentally, goals of tumescent technique are as follows:

1. Homogeneity of infiltration
2. Completeness of local anesthesia
3. Uniformity in size of breast

Technique

Successful delivery of tumescent anesthesia of the breasts includes the following steps (Figure 38-7):

1. With indelible ink, draw six to eight equally spaced radial lines extending from the areola. Along each radial line, draw three or four equally spaced crosshatch marks.
2. Inject small 0.25-ml intradermal blebs of tumescent anesthetic solution at each crosshatch. With skill and attention to the smallest detail, the intradermal blebs can be injected almost painlessly using a sharp 30-gauge needle. Replace the needle when it starts to become dull.
3. Gently stretch the skin between two fingers before slowly sliding the needle into the dermis. Good patient rapport and clinical experience facilitate rapid bleb infiltration.
4. After a bleb has blanched, place a minuscule 1.0-mm adit using a disposable 1.0-mm skin biopsy punch. For cosmetic reasons, minimize the number of these adits in the superomedial quadrant of the breast.
5. Using 25-gauge and 20-gauge spinal needles, initiate the infiltration in the deepest levels first, then more superficially.
6. Infiltrate the solution diffusely, widely, and completely.
7. Using a crisscross pattern, approach each area of tissue from several different directions through different incisions.
8. Adjust the flow rate of the anesthetic solution so that it is neither too slow nor so fast that infiltration is painful or inaccurate.

After infiltration the surgeon should wait at least 30 minutes for detumescence to occur before beginning surgery.

Needles and Fibrous Tissue

A 25-gauge spinal needle with a smaller diameter causes less discomfort as it is advanced through fibrous breast tissue than does a 20-gauge spinal needle. The initial (and incomplete) infiltration of the breast with a 25-gauge needle is intended to provide just enough anesthesia to permit a more definitive infiltration using a 20-gauge spinal needle.

Breasts that contain a relatively high proportion of fat are generally not exceedingly fibrous and are therefore easily infiltrated. On encountering an especially dense, fibrous section of breast tissue, some finesse is required to advance or push a 25-gauge needle through the tissues.

Occasionally the clinician will encounter an exceptionally dense portion of breast tissue, through which a 25-gauge spinal needle cannot easily pass. A needle may bend if pushed too vigorously through resistant breast tissue. Such focally dense tissue can usually be circumvented by pulling back slightly and then advancing toward the difficult tissue from a different direction.

Alternately, the clinician can remove the needle entirely, reenter the breast through a different adit, and approach the resistant tissue along a new path. When infiltrating especially dense breast tissue, it is sometimes easier to use a 20-gauge than a 25-gauge spinal needle.

The infiltrator should always be calm, confident, methodical, and compulsively complete (Figure 38-8).

Pneumothorax

The surgeon must be aware that the infiltration needle can puncture the lung. Attention to detail, patience, and gentleness greatly reduce this risk.

Tension pneumothorax has been reported as a result of general anesthesia and infiltration of local anesthesia in a young woman undergoing breast augmentation.⁴ General anesthesia with endotracheal intubation produces a positive intrathoracic pressure that predisposes to tension pneumothorax.

Similar to the situation in which general anesthesia delays the diagnosis of a punctured abdominal viscus, general anesthesia contributes to a delay in the diagnosis of a tension pneumothorax. A punctured lung is more quickly and easily diagnosed when the patient is alert and conversant.

Surgical Technique

To ensure optimal vasoconstriction after tumescent infiltration into a breast, the surgeon must wait at least 30 minutes before starting liposuction.

The “secret” to being able to perform tumescent liposuction of the female breast totally by local anesthesia is that smaller cannulas cause less pain. The width or girth of a cannula is directly proportional to the degree of pain associated with liposuction.

Multiple small, round cannula apertures provide the greatest efficiency in terms of cannular design. When microcannular efficiency is measured in terms of the volume (ml) of aspirated supranatant fat per 100 strokes of the cannula, the Capistrano-style Brest microcannula is very efficient. Three cannulas have been specially designed for liposuction of the female breast: 16 gauge, 12 cm (4.75 inches) long; 14 gauge, 15 cm (6 inches) long; and 12 gauge, 23 cm (9 inches) long.

Liposuction is initiated in the deepest planes of the breast close to the chest wall. From among the radial lines drawn on the breast, a convenient line is chosen and liposuction begun through the adit most distant from the areola. The cannula is first directed through the deepest plane of fatty breast tissue tangential to the chest wall.

The paths of the cannula tunnels radiate from the adit. From each adit the radiating pattern of tunnels intersects and overlaps the tunnels that radiate from other adits. This patterned approach replicates the sequence used for the infiltration process. A regular pattern of radiating cannula strokes provides uniform liposuction (see Figure 38-8).

Some of the pain associated with liposuction is the result of pulling or pushing on fibrous connective tissue elements that are attached to deeper, nonanesthetized structures. Another source of pain is the surgeon’s excessively firm grip on the patient’s tissues.

The 16-gauge cannulas can penetrate most tissue with relatively little resistance and thus little discomfort to the patient. Creating a network of 16-gauge tunnels allows the passage of a larger, 14-gauge cannula with less resistance and discomfort than would otherwise be possible. The use of a 12-gauge breast cannula is rarely necessary.

The 16-gauge Capistrano cannula, 12 cm (4.75 inches) long, is used to initiate the liposuction. The tiny crosssectional profile of a 16-gauge cannula allows it to be advanced through dense portions of the glandular breast tissue with relative ease. Minimal resistance means minimal discomfort with breast liposuction.

After initially fenestrating the breast tissue with 16-gauge cannulas, the larger 14-gauge (15 cm in length) Brest cannula will more easily pass through the prepared network of tunnels. The 14-gauge cannula is used for removing the largest volume of tissue, which is mostly adipose tissue, with some glandular elements.

Each breast should be treated systematically so that both breasts are treated equally. The cannula should not linger for too many thrusts within the same tunnels. Rather, the paths should spread out radially with uniform density from each incision site. The patterns of paths radiating from different incisions should intentionally crisscross and overlap each other. Uniformity with homogeneity of tissue extraction is the goal.

With gentle and skillful surgical technique, female breast liposuction can be routinely accomplished totally by local anesthesia.

Postoperative Care

The breast is unique in its postliposuction compression requirements. Most other areas of the body do not require an exceptionally high degree of compression after liposuction. The breasts are an exception and require greater compression for the first 12 to 18 hours after liposuction.

The extra compression is necessary to encourage a maximal degree of hemostasis. Empirically I have observed that, without adequate external compression in the immediate postliposuction period, the breasts tend to develop bruising and hematomas (Figure 38-9).

Adjustable Breast Compression

Special postoperative breast garments have been specifically designed to allow easily adjustable compression. If the compression is too slight, there is a risk of subcutaneous bleeding. If the compression is too tight, the patient may experience pain or difficulty breathing. The solution to this situation is to use an adjustable compression garment so that the patient can easily readjust the compression to the maximum comfortable level at any time.

Postliposuction breast compression should be maximal for the initial 12 to 18 hours. The day after surgery, while there is some drainage, the compression is adjusted to a more moderate level. Ultimately, after all drainage has ceased, the compression is again adjusted to a minimal level but still sufficient to provide comfort and support.

Trimodal Compression

The term trimodal compression is used to emphasize that three sequential and decreasing degrees of compression are used after breast liposuction.

The first 12 to 18 hours after breast liposuction requires the maximum compression that the patient can tolerate comfortably. This relatively intense compression is necessary to minimize the risk of postoperative hematomas and to limit the amount of bruising.

After the initial phase, continuous, moderately firm compression is required to optimize drainage and minimize postliposuction edema. This intermediate degree of compression is maintained for at least 48 hours and for 24 hours beyond the time when all drainage has ceased.

Beyond the 24 hours after all drainage has stopped, compression is needed to minimize the risk of seromas and to optimize patient comfort. At this point, only a mild to moderate degree of compression is required. The intensity of the compression should be selected to maximize patient comfort. This mild to moderate compression is typically maintained 5 to 7 days or more. Maintaining compression more than a week after surgery can be at the patient’s discretion.

Subsequently, many patients prefer to use a sports bra for several weeks until a regular bra can be worn comfortably.

A compression garment or binder must be not only comfortable but also securely applied to prevent slipping from its intended location. An unsecured abdominal binder placed around the chest and over the breasts can readily shift position during sleep or normal ambulatory activity. The weight and mobility of the breasts, the funneled shape of the thorax, and the narrow girth of the waist cause the entire dressing to migrate toward the hips (Figure 38-10).

Years of experience and numerous modifications have helped me to develop an effective, comfortable, and reliable system that uses absorptive pads, a spandex torso garment, and highly compressive abdominal binders (Figure 38-11).

The HK Breast-Torso Garment permits comfortable, adjustable, secure, high-pressure compression for breasts, abdomen, or hips and waist after tumescent liposuction. Because of the prolonged local effect of tumescent anesthesia, most patients require no postoperative analgesia other than acetaminophen (Tylenol) (Figure 38-12).

The garment’s degree of compression should be as tight as possible but still comfortable. If the patient is uncomfortable, the degree of compression should be adjusted.

The greatest tolerable compression is maintained until the next morning, when the pads are removed while the patient takes a shower. After showering the patient applies new pads every 12 hours until all drainage has ceased, usually less than 48 hours after surgery.

After tumescent liposuction of the female breast, postoperative swelling gradually decreases over 6 months (Figure 38-13).

Pitfalls and Special Considerations

The only complication that has occurred with tumescent liposuction of the female breast has been two episodes of excessive bruising caused by inadequate compression; these resolved spontaneously without sequelae (see Figure 38-9).

Complications of Reduction Mammoplasty

The complications of traditional excisional reduction mammoplasty include loss of sensation or reduced sensation to the nipple and areola and interference with future breast feeding.⁵ Because of the minimal trauma to glandular breast tissue and the normal appearance of postliposuction mammograms, breast reduction by tumescent liposuction should not be expected to interfere with lactation after a subsequent pregnancy.

Galactorrhea is a rare complication but has been reported in three cases of excisional mammoplasty.⁶ Hypertrophic, keloid, painful, or disfiguring scars may occur after excisional breast reduction.

Nipple necrosis is probably unique to traditional mammoplasty by excision. Some complications of traditional reduction mammoplasty, however, might also be encountered with tumescent liposuction of the female breast.

Any surgery of the breast can result in postoperative calcifications, which might hinder the mammographic detection of breast cancer.⁷ Patients contemplating tumescent liposuction for breast reduction must be informed of this risk factor. Mammograms should be performed before surgical reduction of the female breast and 3 months after surgery.⁸

Although I have not seen postoperative calcifications of the breast detected by mammogram after tumescent liposuction, such calcifications may occur in some patients. An estimate of the incidence of postoperative breast calcifications will require a larger series of patients followed over a longer time.

Breast Lumps After Liposuction

Liposuction of the female breast is occasionally associated with temporary lumpiness that can persist for many weeks after surgery. This transient lumpiness is similar to the temporary palpable lumpiness experienced after liposuction of the abdomen and thighs. In either situation, this lumpiness is usually not visible.

A breast lump is more worrisome than subcutaneous lumps in another location and thus demands special attention. Distinguishing between a benign postliposuction lump and a possible malignancy requires a preoperative baseline mammogram and a documented preoperative breast examination. If a new breast lump appears within 1 or 2 months after breast liposuction and then decreases in size over subsequent weeks, it is unlikely that the lump is malignant, and invasive diagnostic tests are probably unnecessary. A postoperative mammogram is recommended 3 to 6 months after female breast liposuction.

Mammograms

Mammograms after tumescent liposuction have been within normal limits for my patients. Comparisons between preoperative and postoperative mammograms have revealed only one patient with calcification, which was different from calcifications associated with breast cancer. The only other radiologic changes have been (1) a notable reduction in breast size and (2) occasional mild fibrosis.

Postoperative mammograms should be considered to rule out existing malignancies and to establish an up-to-date baseline mammogram with which future mammograms might be compared. Similarly, after reduction mammoplasty, mammograms should be done within 3 to 6 months to establish new baseline mammograms.

With traditional excisional mammoplasty, postoperative inflammatory nodules and lipid-filled pseudocysts may occur. These changes may make it difficult to interpret future mammograms without good baseline mammograms for comparison.

Based on risk-benefit analyses, regular mammograms are not recommended for all women. Female patients who have had a reduction mammoplasty, however, might benefit from reliable baseline mammograms because of their surgically modified anatomy and mammographic status.

Contraindications

The relative contraindications for tumescent breast reduction include the following:

1. Excessively pendulous breasts
2. Excessively large breasts
3. Presence of palpable breast mass
4. Significant fibrocystic disease
5. Unrealistic expectations

Tumescent liposuction for breast reduction surgery in any patient with a significant family history of breast cancer requires extremely careful consideration and informed consent.

Fat Transplantation

Some surgeons have proposed and performed augmentation mammoplasty by autologous fat transplantation. No longitudinal studies have documented the safety, efficacy, and potential long-term complications of this breast augmentation. Potential complications have included fat necrosis and liponecrotic cysts.⁹

It seems most appropriate to regard fat transplantation into the female breast as an experimental procedure that requires all the human studies research protocols for patient protection.

References

1. Courtiss EH: Reduction mammaplasty by suction alone, Plast Reconstr Surg 92:1276-1284, 1993.
2. Gray LN: Liposuction breast reduction, Aesthetic Plast Surg 22:159-162, 1998.
3. Mackinnon SE: Discussion: preoperative and postoperative nipple-areola sensibility in patients undergoing reduction mammaplasty, Plast Reconstr Surg 92:815-818, 1993.
   3a.       Cruz-Korchin NI: Fat content in the breast reduction mammoplasty. Poster presentation at American Society of Plastic Surgery meeting, New Orleans, 1999.
4. Kaye AD, Jahr WM, Nossaman BD, Youngberg JA: Local anesthesia infiltration as a cause of interoperative tension pneumothorax in a young healthy woman undergoing breast augmentation with general anesthesia, J Clin Anesth 7:422-424, 1995.
5. Gonzalez F, Brown FE, Gold ME, et al: Preoperative and postoperative nipple-areola sensibility in patients undergoing reduction mammaplasty, Plast Reconstr Surg 92:809-814, 1993.
6. Schuurman AH, Assies J, van der Horst CMAM, Bos KE: Case report: galactorrhea after reduction mammaplasty, Plast Reconstr Surg 99:951-954, 1993.
7. Leibmann AJ, Styblo TM, Bostwick J: Mammography of the postreconstruction breast, Plast Reconstr Surg 99:698-704, 1977.
8. Brown FE, Sargent SK, Cohen SR, Morain WD: Mammographic changes following reduction mammaplasty, Plast Reconstr Surg 80:691, 1987.
9. Maillard GF: Liponecrotic cysts after augmentation mammoplasty with fat injections, Aesthetic Plast Surg 18:405-406, 1994.

Figure 38-1 Liposuction of one breast during tumescent liposuction course demonstrates breast elevation and reduction. A, Preoperative view, with left breast larger than right breast. B, One day after surgery, with treated left breast already elevated and smaller. C, Six weeks after tumescent liposuction totally by local anesthesia using microcannulas, with significant improvement in size, shape, weight, and position of treated left breast compared with untreated right breast. Right breast was treated during subsequent teaching course. Breast size progressively decreases for up to 6 months after microcannular breast reduction.

Figure 38-2 Another participant in hands-on liposuction course had liposuction of left breast; 60 days later, during another liposuction course, right breast was liposuctioned. A, Breast volume measurements before liposuction were 1150 ml (right breast) and 1340 ml (left breast), exclusive of breast’s axillary extension. B, Preoperative breast markings on breast and axillary breast extension. C, Approximately 685 ml and 150 ml of supranatant fat was aspirated from the left breast and left axillary breast extension, respectively. Recall that 16% of supranatant fat is residual physiologic saline. D, Sixty days after liposuction of left breast, its volume was 742 ml, corresponding to a 45% reduction in breast volume. Patient’s bra-cup size for left breast changed from a DD to C.

Figure 38-3 A and B, Preoperative anterior and lateral views. C and D, Postoperative anterior and lateral views demonstrating both reduction in size and elevation of breasts. Apparent skin retraction, or elasticity, was achieved without superficial liposuction. Excessive superficial liposuction is not necessary and can cause dermal necrosis.

Figure 38-4 Parasagittal section through female breast illustrating relative distribution of fibrous and fatty content as well as mammary glandular tissue and lactiferous ducts. Cooper’s ligaments are fibrous structures that give elastic support to pendulous breast.

Figure 38-5 Technique for measuring volume of breast by water-displacement method. A, Four-liter beaker is filled to rim with warm water. B, Immersion of breast into beaker causes displacement of water equal to volume of breast. C, Volume of displaced water is then determined by measuring volume required to refill beaker.

Figure 38-6 Tumescent breast after infiltrating volume of anesthetic solution equivalent to preoperative breast volume.

Figure 38-7 Preoperative drawings on female breast differ from topographic contour drawings used on other areas. Lines radiating from areola provide efficient geometric grid to help ensure uniform distribution of both infiltration and liposuction. A, Measurement of areolar diameter and distance of breast from umbilicus. B, Placement of crosshatch marks on radial lines. C, Preoperative view. D, Postoperative results.

Figure 38-8 Patterns for tumescent infiltration and tumescent liposuction of female breast are basically the same. For example, infiltration needle first radiates out along deepest plane and then along second and third planes. When this pattern is repeated through each of numerous other adits, overall effect is to ensure complete infiltration throughout breast. Similar pattern is used for paths of liposuction cannula.

Figure 38-9 Insufficient breast compression after liposuction of female breast increases risk of poor hemostasis, excessive bruising, and possible hematomas. This patient had asymmetric breasts and sought unilateral breast reduction by liposuction to avoid asymmetric scar. A, Postliposuction compression consisted of only a tightly wrapped elastic bandage. B, Inadequate compression resulted in excessive bruising.

Figure 38-10 Postoperative dressing of absorptive pads and tightly compressive binders wrapped with elastic bandage. This arrangement proved to be inadequate to hold breast compression dressing securely in place. After patient had arrived at her home, dressing slipped from intended position, necessitating house call for reapplication.

Figure 38-11 Prototype HK Breast-Torso Garment. Patient can move arms with full range of motion; Velcro strips prevent displacement of compression binders; and binders are adjustable.

Figure 38-12 Application of HK Breast-Torso Garment. A, Precut segment of tubular elastic netting is slipped over feet and pulled up onto upper abdomen. One or more HK Pads are then placed on breasts. These custom-designed, extra-thick absorptive pads contain superabsorbent powder (SAP). B, Using strip of 5-cm (2-inch)–wide paper tape, inferior margin of HK Pads is taped onto skin to hold them against skin and minimize leakage of anesthetic solution beyond pads. Netting is then pulled up from abdomen onto chest to secure absorptive pads on breasts. C, Breast-torso garment is applied by pulling it over feet and legs, then onto torso. Arms are placed through sleeves. D, Garment is in place and arranged to fit comfortably. Two parallel, 3-cm (2.2-inch)–wide, vertical strips of Velcro hooks are sewn onto anterior portion of garment. E, A 22.5-cm (9-inch)–wide elastic binder is placed over lower breast and upper abdomen. Velcro adheres to fluffy fabric of elastic abdominal binders and prevents binder from slipping or shifting out of position. F, Second binder is applied directly over breast and arranged so that it overlaps first binder and contacts Velcro strips. This binder should be placed as tightly as patient can comfortably tolerate.

Figure 38-13 Achieving final result after female breast reduction by tumescent liposuction using open drainage and trimodal compression, with resolution of postoperative edema, typically requires 2 months or more. A and B, Preoperative views before breast reduction by tumescent liposuction. C and D, One day after breast liposuction. E and F, Ten days after liposuction. G and H, Sixty days after tumescent liposuction reduction mammoplasty.

BOX 38-1 Risks of Excisional Breast Reduction

Hypertrophic scars

Breast asymmetry

Abnormal appearance to nipple-areolar complex

Impaired nipple sensation

Nipple necrosis

Hematoma

Seroma

Fat necrosis with pseudocyst formation

Parenchymal scarring with mammogram abnormalities