|Year : 2022 | Volume
| Issue : 6 | Page : 909-915
Preferences of different breast reduction techniques: Survey of board-certified plastic surgeons
A Marouf1, H Mortada2, K Almutairi3
1 Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University; Department of Plastic Surgery and Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia
3 Department of Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
|Date of Submission||19-Nov-2021|
|Date of Acceptance||31-Jan-2022|
|Date of Web Publication||16-Jun-2022|
Dr. H Mortada
Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University and Department of Plastic Surgery and Burn Unit, King Saud Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Breast reduction is a common and safe procedure with predicted cosmetic outcomes. Many techniques have evolved over the recent decades. Aims: The aim of this study is to determine what type of breast reduction techniques are currently preferred among board certificated Saudi plastic surgeons and assess the surgeons' satisfaction, surgeon-reported patient satisfaction, and complication rates post breast reduction with the preferred techniques. Materials and Methods: This is a cross-sectional questionnaire-based study. The questionnaire was adapted from previously published studies and distributed to a small group before full-scale distribution to Saudi plastic surgeons by email and communication groups. Results: The mean age of the participants was 45.4 (± 8.9). Most participants were males (82%), and the majority held a Saudi board (44%), and 20% held a Canadian board. Significant differences between different board certifications, held fellowship, and years of experience emerged in terms of surgical preferences. The two most common complications reported by surgeons were suture splitting (34%) and excess scarring (24%). Conclusions: In Saudi Arabia, inverted T resection patterns with superior or superomedial pedicle designs are the standard techniques used in breast reduction, with higher satisfaction rates and fewer complications. Surgical preferences were significantly different between surgeons based on their training and held fellowships.
Keywords: Board certification, breast reduction, outcomes, surgical preferences
|How to cite this article:|
Marouf A, Mortada H, Almutairi K. Preferences of different breast reduction techniques: Survey of board-certified plastic surgeons. Niger J Clin Pract 2022;25:909-15
|How to cite this URL:|
Marouf A, Mortada H, Almutairi K. Preferences of different breast reduction techniques: Survey of board-certified plastic surgeons. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 6];25:909-15. Available from: https://www.njcponline.com/text.asp?2022/25/6/909/347619
| Introduction|| |
One of the commonly performed surgeries by plastic surgeons is breast reduction, which is a safe procedure and has a well-predicted cosmetic result. The outcomes of breast reduction surgeries are associated with improvement in the health-related quality of life, and most patients who undergo breast reduction are pleased with their results. Consequently, when it comes to the technicalities of breast reduction, the main aim is to safely transfer the nipple-areola complex with its sensation and vascularity while maintaining a cosmetically acceptable breast shape with hidden scars.
Breast reduction techniques have evolved in the recent decade, especially regarding pedicle choice and incision placement. Traditionally, the standard inferior pedicle technique, first mentioned by Ribeiro, is associated with the T inverted scar, and the popularity of such technique is due to its consistent and safe outcome. On the other hand, the drawback of this technique is the potential risk for the breast to protrude out over time, an adverse outcome known as “Bottoming-out” due to the lack of parenchymal support and long scars that detract from the aesthetic result, especially the medial limb of the incision. In the end, patients and plastic surgeons are satisfied after the breast reduction, but the most likely reason for dissatisfaction is the scarring. Another well-known technique is vertical breast reduction, first mentioned by Dartigues and later reintroduced by Lassus, which is a technique that avoids the inframammary fold scar. Lejour modified Lassus' technique,, leading to the popularization of the technique in South America and Europe; however, surgeons in North America have been more reluctant to adopt this technique due to fear of complications, lack of proper training in the technique, uncertainty regarding perfusion of the superior pedicle, and apprehension about completing surgery without seeing the final breast shape., A study by Hidalgo et al. discovered that 74% of surgeons preferred inferior/central pedicles with T scar inverted techniques, and a study by Rohrich et al. showed that 75.5% of the American Society of Aesthetic Plastic Surgeons preferred and used inferior pedicle incision techniques. On the other hand, only 15.5% of plastic surgeons preferred limited incision techniques, including short and vertical scar methods. In North America, recent modifications such as the Hall-Findlay technique, which uses a medial pedicle and vertical scar, have been efficient and safe. Despite these reassuring studies, comfort with the vertical techniques lags behind Europe. A retrospective study by Menke et al. involving 799 breast reduction patients showed that 52% of German plastic surgeons were performing breast reduction surgery by using the vertical scar technique, while 45% used the inverted T scar techniques. The most common complication they faced was wound dehiscence (21.5%). Another study conducted by Iwuagwu et al. reported that 67% of plastic surgeons in the UK and Ireland used the inferior pedicle technique.
There has been no study to date assessing Saudi plastic surgeons' preference regarding breast reduction techniques. Hence, this cross-sectional survey-based study among board-certified plastic surgeons in Saudi Arabia aims to determine what type of breast reduction techniques are currently preferred and assesses the surgeons' satisfaction, surgeon-reported patient satisfaction, and complication rates post breast reduction with the preferred techniques.
| Methods|| |
In March 2021, a 34-item breast reduction pilot electronic questionnaire was distributed to 15 board-certified plastic surgeons. It was then distributed to plastic surgery communication groups and email addresses. English-speaking physicians, who fit the aforementioned criteria, and board-certified plastic surgeons practicing in Saudi Arabia were invited to participate. The need for an ethical approval was waived due to the nature of the study. All participating physicians had consented prior to completing the questionnaire.
The questionnaire was adapted from previously published studies,, and consisted of three parts. The first part collected demographic information and training details, including age, gender, handedness, region of training, and fellowships, if any. The second part focused on the participants' experiences and occupations, including questions about their years of experience, number of work hours a week, type of center, whether the service is governmental or private, and an approximation of the number of breast reduction surgeries performed. The third part was about surgical technique preferences, satisfaction and complications, and pre- and post-operative care preferences (such as the use of antibiotics, adrenaline solution, and tumescent fluid).
Data were checked for completeness, and errors were corrected. The normality of the distributions of continuous variables was checked using the Shapiro-Wilk and Kolmogorov–Smirnov tests. Their results indicated that none of the variables were normally distributed. Age was described as the mean (± standard deviation). Categorical variables were described as frequencies (%).
Demographic, training, and job-related variables were compared with surgical preferences using Chi-squared, fisher exact, Kruskal-Wallis, and Mann-Whitney U tests.
| Results|| |
The mean age of the questionnaire participants was 45.4 (± 8.9) years. Most of the participants were male (82%) and right-handed (96%).
Out of all the questionnaire participants, 44% held a Saudi board in plastic and reconstructive surgery, 20% held a Canadian board, and 46% had a fellowship in aesthetics, while a minority had fellowships in breast or reconstruction.
More than half (56%) of the participants had the experience of 10 years or less, while only 24% had more than 40 years of experience. Three-quarters of the participants worked between 40 and 60 hours per week, and more than half served in both the government and private sectors. [Table 1] demonstrates the participants characteristics.
Handedness and surgical preferences [Table 2]
Handedness did not significantly differ in terms of surgical preferences, except for the use of adrenaline, in which most right-handed surgeons (77.1%) injected adrenaline compared to none of the left-handed surgeons.
Training and surgical preferences [Table 2]
Different training resulted in significant differences in all preferences in our questionnaire. For the preferred pedicle design, most Saudi board physicians (81.8%) and all French board physicians (100%) preferred superior or superomedial design, while only 50% of the Canadian board physicians preferred them.
For the resection pattern, more than 80% of all plastic surgeons preferred the inverted T pattern, except for Pakistani board physicians, who preferred the vertical pattern the most (75%).
For reduction type, it is notable that the wise pattern was the most frequently preferred reduction type in Saudi (59.1%), Canadian (60%), French (100%), and Pakistani (50%) board physicians. Only German board physicians preferred McKissock (37.5%) the most.
Plastic surgeons of all boards were mostly accepting of performing breast reduction on smokers, except Pakistani board plastic surgeons who, as a majority, preferred not to (75%).
Most French board physicians (75%) did not prefer adrenaline injections in breast reduction procedures. In contrast, Saudi (72.7%), Canadian (80%), German (87.5%), and Pakistani (100%) board physicians prefer to inject adrenaline.
Trainees of all countries preferred to perform breast reduction in patients with a body mass index (BMI) of 25–29.
Fellowships and surgical preferences [Table 2]
Surgeons who held fellowships in aesthetic plastic surgery preferred the superomedial pedicle design more than those without the fellowship (47.8% vs. 37%). In addition, the most preferred reduction types were wise pattern and Hall-Findlay (47.8% and 21.7%, respectively) compared to those who did not hold a fellowship in aesthetics, in which most surgeons preferred the wise pattern and inferior pedicle.
The vertical resection pattern was the preferred pattern in surgeons who had a fellowship in reconstruction (66.7%) compared to the inverted T pattern in those without the fellowship.
Workplace and preferences
The type of center a surgeon worked in showed significant differences in the type of pedicle design, in which most of the secondary (2ry) center surgeons (48.1%) preferred the superior pedicle design, while 61% of the tertiary (3ry) center surgeons preferred the superomedial design. Additionally, surgeons in 3ry centers (69.6%) were more likely to prefer a BMI of at least 25–29 kg/m to perform a breast reduction, compared to only 55.6% of 2ry center surgeons.
All surgeons serving only in government hospitals preferred a normal BMI to perform breast reduction, while only 11.1% of surgeons working in both government and private sections preferred a normal BMI.
Outcomes and surgical technique [Table 3] and [Table 4]
Patient satisfaction significantly differed in terms of the surgeon-preferred type of reduction. The majority of surgeons who preferred wise pattern reduction reported patient satisfaction scores of 4 and 5. The majority of those who preferred limited incision reported patient satisfaction scores of 2 and 3.
Complication rates reported by surgeons significantly differed in terms of operation in smokers and the resection pattern. The two most common complications reported by surgeons were suture splitting (34%) and excess scarring (24%).
| Discussion|| |
In the last decade, breast reduction techniques have evolved, particularly pedicle selection and incision placement. Different reported techniques are in a constant state of evolution, and their complications are commonly discussed. Moreover, the need for breast reduction surgeries is increasing; breast-related procedures, in general, represent more than 50% of all aesthetic surgeries, and breast reduction is around 6% of aesthetic claims.
Our findings shed light on the current trends of breast reduction technique preference among various board-certified plastic surgeons, its association with the surgeons' demographics and background, assessment of the surgeons' report of patient satisfaction, and post-breast reduction complication rates. As assumed, the superomedial pedicle (42%) and superior pedicle (36%) were the most preferred pedicle designs. The inverted T resection pattern (80%) and wise pattern reduction (52%) techniques were the most popular, and these findings are different from those of a previously published article among Canadian plastic surgeons, which showed that the inferior pedicle and wise patterns (75%) were the most commonly preferred techniques. However, Canadian board plastic surgeons had similar preferences, with 80% preferring either inferior pedicle or wise patterns. Another similar study was conducted during the annual meeting of the American Society of Plastic and Reconstructive Surgeons among 190 American plastic surgeons. They found that the most preferred techniques were the inferior pedicle (74%) and Lejour techniques (12%).
Given the restriction of operating field laterality, surgeons frequently aim to improve their technical dexterity, and the hand dominance of the surgeon is a significant aspect. A retrospective chart review study carried out among breast surgeons showed no significant relationship between handedness and technicality. This corresponds with our findings, as there were no significant differences in surgical preferences based on handedness, except for the use of adrenaline, which was used by most of the right-handed surgeons (77.1%) compared to none of the left-handed surgeons.
Our findings demonstrated that the superior (36%) or superomedial (42%) pedicle design was the most preferred among Saudi board-certified (81.8%) and all French board-certified surgeons (100%), in contrast to earlier findings by Nelson et al. among Canadian plastic surgeons which showed that the inferior pedicle was the most used. This coincides with our results, as the inferior pedicle was the most commonly used among Canadian board-certified participants (50%). Regarding preferred resection patterns, the inverted T resection pattern was the most preferred among French (100%), Egyptian (100%), German (87.5%), Saudi (81.8%), and Canadian (80%) board-certified surgeons. These conclusions indicate that training background can influence surgical approach preference; however, some surgeons may have modified their practices to include different techniques to perform breast reduction to accommodate a more extensive range of breast sizes and shapes and, most importantly, patient satisfaction.
In the literature, the total complication rate of breast reduction might range from 5–53%.,, Davis et al. evaluated 406 bilateral breast reductions between 1981 and 1992, which is one of the most comprehensive studies, finding that suture splitting and excess scarring were the most common complications. The findings of this survey-based study are intended to provide an overview of the current breast reduction surgery technique trends. In Saudi Arabia, inverted T resection patterns with superior or superomedial pedicle designs are the standard techniques used in breast reduction, with higher satisfaction rates and fewer complications.
Limitations and future recommendations
The most significant advantage of this study was that rather than relying on a single center or a single group of surgeons, this study gathered data from a large and diverse group of surgeons from various practice types and experience levels. However, this study had some limitations, including the descriptive cross-sectional nature of this study and the possibility of bias. Furthermore, the moderate sample size, in comparison to previous similar articles,, could affect the overall results. It is critical to recognize the inherent response bias of the survey as breast plastic surgeons who have had high success rates and who are more experienced in breast surgery might be more likely to participate in the survey. However, this hypothesis contradicts our results, as only 14% of the participants had a fellowship in breast surgery. Lastly, high satisfaction ratings and low complication rates reflect reporting bias. The overall complication rate in this study was <5%, which is lower than most of the breast reduction complication rates described in the literature.,,, Consequently, we recommend that future studies be conducted with larger sample sizes and better response rates. Although the practical benefits of breast reduction are widely documented, there is always room for improvement. We hope that the plastic surgery society will continue to support efforts to refine existing procedures and develop new breast reduction procedures.
| Conclusion|| |
This questionnaire-based study's findings provide an overview of the current trends in breast reduction surgical procedures. Our study demonstrated that the superomedial pedicle was the most preferred pedicle design and that the inverted T resection pattern and wise pattern reduction techniques are being widely adopted among board-certified plastic surgeons; consequently, these techniques offer reproducibly good outcomes with low complication rates. Future research should include larger sample size and a higher response rate.
The authors would like to thank Editage for their English editing services.
A.M.: concept, design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, statistical analysis, manuscript editing, and manuscript review.
H.M.: concept, design, definition of intellectual content, literature search, clinical studies, experimental studies, manuscript editing, and manuscript review.
K.A.: literature search, clinical studies, manuscript preparation, manuscript editing, and manuscript review.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Blaine C, Subbio C, Eid S, Murphy R. Reduction mammaplasty trends. Ann Plast Surg 2012;69:344-6.
Miller B, Morris S, Sigurdson L, Bendor-Samuel R, Brennan M, Davis G, et al
. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg 2005;115:1025-31.
Schnur P, Schnur D, Petty P, Hanson T, Weaver A. Reduction mammaplasty: An outcome study. Plast Reconstr Surg 1997;100(Suppl 1):875-83.
Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg 1975;55:330-4.
Robbins T. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg 1977;59:64-7.
Adams W. Reduction mammaplasty and mastopexy. Selected Readings Plast Surg 2002;9:29.
Davis GM, Ringler SL, Short K, Sherrick D, Bengtson BP. Reduction mammaplasty: Long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg 1995;96:1106-10.
Dartigues L. Le Traitement Chirurgical du Prolapsus Mammaire. Bruxelle: Impr. Lielens; 1925.
Lassus, C. Possibilités et limites de la chirurgie plastique de la silhouette féminine. Hopital 1969;801:575.
Lejour M, Abboud M, Declety A, Kertesz P. Reduction of mammaplasty scars: From a short inframammary scar to a vertical scar. Ann Chir Plast Esthet 1990;35:369-79.
Lejour M. Vertical mammaplasty: Early complications after 250 personal consecutive cases. Plast Reconstr Surg 1999;104:764-70.
Nelson R, Colohan S, Sigurdson L, Lalonde D. Practice profiles in breast reduction: A survey among canadian plastic surgeons. Can J Plast Surg 2008;16:157-61.
Hidalgo DA, Elliot LF, Palumbo S, Casas L, Hammond D. Current trends in breast reduction. Plast Reconstr Surg 1999;104:817-8.
Rohrich R, Gosman A, Brown S, Tonadapu P, Foster B. Current preferences for breast reduction techniques: A survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004;114:1724-33.
Hall-Findlay E. Vertical breast reduction with a medially-based pedicle. Aesthet Surg J 2002;22:185-94.
Menke H, Eisenmann-Klein M, Rüdiger Olbrisch R, Exner K. Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: A preliminary report. Ann Plast Surg 2001;46:594-600.
Iwuagwu O, Platt A, Drew P. Breast reduction surgery in the UK and Ireland–Current trends. Ann R Coll Surg Engl 2006;88:585-8.
Okoro S, Barone C, Bohnenblust M, Wang H. Breast reduction trend among plastic surgeons: A national survey. Plast Reconstr Surg 2008;122:1312-20.
Daane S, Rockwell W. Breast reduction techniques and outcomes: A meta-analysis. Aesthet Surg J 1999;19:293-303.
Gorney M. Patient selection-the illusion and the reality. In: Proceedings of the Senior Residents Conference, Milwaukee, Wis., March2004.
Greene BHC, Seal SF, Cluett J, Fitzpatrick DG, Rideout A, Jewer DD. A survey of Canadian trends in outpatient reduction mammaplasty. Eur J Plast Surg 2020;43:201-3.
Luvisa K, Fan KL, Black CK, Wirth P, Won Lee D, Del Corral G, et al
. Does surgeon handedness or experience predict immediate complications after mastectomy? A critical examination of outcomes in a single health system. Breast J 2020;26:376-83.
Cunningham BL, Gear AJL, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg 2005;115:1597-604.
Roehl K, Craig ES, Gómez V, Phillips LG. Breast reduction: Safe in the morbidly obese? Plast Reconstr Surg 2008;122:370-8.
Schumacher HHA. Breast reduction and smoking. Ann Plast Surg 2005;54:117-9.
[Table 1], [Table 2], [Table 3], [Table 4]