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Patient X is a 20-year-old Caucasian woman who suffers from symptomatic macromastia. A Wise pattern skin resection was drawn, beginning by marking a point 20.5cm from the suprasternal notch on each breast along the breast meridian, indicating the apex of the skin resection and position of the future nipple placement. A triangle was then drawn with sides of 8cm each and a base of 7cm, with the apex again at the point noted above. The base of the inferior pedicle was drawn by marks 5.5cm to either side of this intersection, giving a pedicle with a 11cm base. Additional anatomic landmarks were also marked, including the suprasternal notch, and the sternal midline.
We began our operation on the patient's right side. The surgeon began by elevating the breast and placing a lap gauze around the base to create a breast tourniquet. A 42mm nipple sizer was used to mark out the planned area of nipple and areolar skin. The planned area of skin de-epithelization was then marked. The surgeon began de-epithelizing the pedicle, first incising to the dermis around the nipple, and then cutting through the dermis on the edges of the pedicle. A #10 scalpel was then used to elevate the skin off of the pedicle while the breast was held up and retracted for the dermis to be removed. Once the skin was removed, the pedicle was inspected for any remaining dermis, which was removed with an Iris scissor. The pedicle was then irrigated with antibiotic-containing saline, and hemostasis achieved with Bovie electrocautery.
At this point, the skin flaps were stapled closed, and the patient sat up and inspected. Areas requiring additional resection were noted, and the patient returned to a supine position and staples removed. Additional dissection of the breast tissue was performed as needed. Next, the skin flaps were sutured down in the inverted T shape. A layered closure was performed with a series of interrupted 3-0 Monocryl sutures in the deep dermis and a running subcuticular 5-0 Monocryl superficially.
An essentially identical procedure was then performed on the opposite side in mirror image. Total tissue removed was 583 grams on the left side and 604 grams on the right side.
Finally, the nipples were brought out on both sides. The patient was sat up again, and the sites of the nipples were marked with 42mm sizers. The patient was then returned to a supine position. A #10 scalpel was then used to cut along the circle, and the subcutaneous fat divided. This tissue was passed off and included with the specimens for the respective side. The nipple was then brought out through the opening and sutured in place with subcuticular 3-0 Monocryls, followed by a simple running stitch of 5-0 fast absorbing gut.
Caucasian woman who suffers from symptomatic macromastia, including pain in her back and neck that is refractory to treatment with NSAIDS, shoulder grooving from her bra straps, social embarrassment, and difficulty with exercise due to the size of her breasts.
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bleeding, infection, damage to other structures, patient dissatisfaction
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Dr. Keith Wolter
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Review Breast Reduction Mammoplasty: Inferior Pedicle Technique.