Secondary Breast Reduction: Outcome and Literature Review.
Kerrigan has described seven symptoms in patients with macromastia.  These are back pain, neck pain, shoulder pain, arm pain, numbness on arms, rashes under the breasts, and grooving from bra straps on shoulders. A breast reduction surgery that was planned in a patient who had previous breast reduction surgery due to recurrence of these symptoms after a certain period is called breast rereduction or secondary breast reduction.
The reasons that can lead to a secondary breast reduction surgery include insufficient volume excision at the first surgery, development of pseudoptosis due to breast deformity, or recurrence of macromastia. [1-3] Inadequate volume resection may be due to technical reasons or the patient's request. Although there are various methods[4,5] and three-dimensional programs that calculate predicted resection volume before surgery, they are not widely used due to low feasibility and inconsistency. To understand the patient's expectations is important in determining the amount of resection.
The development of pseudoptosis due to breast deformity is another factor that leads to secondary surgery. Pseudoptosis occurs most commonly after breast reductions with inferior pedicle inverted-T-scar technique. [7,8] Studies have shown that breast tissue takes its final shape within 1 year after breast reduction. Therefore, we encounter pseudoptosis within the 1st year after surgery. [9,10]
Recurrence of macromastia should be carefully considered. Weight gain, hormonal changes, lactation, and pregnancy may cause recurrence of macromastia.  Juvenile gigantomastia should also be considered in adolescents as a reason for postoperative recurrence of macromastia. 
However, although breast cancer risk reduces with reduction mammoplasty, patients with secondary hypertrophy, subsequent unilateral asymmetry, breast mass, skin irregularity, and retraction at the nipple should be evaluated for breast cancer.
Studies have shown that breast edema reduces 8%-14% in 3 months after surgery, breast shape is stabilized in 9 months, and breast shape can change only slightly after 1 year. [9,10] Therefore, an interval of at least 1 year is recommended between two surgeries.
Patients scheduled to undergo secondary breast reduction surgery are assessed with a detailed history and physical examination to identify the etiology. Thereafter, the patients are also evaluated with imaging methods to detect any preoperative mass, pathological lymph node, fatty necrosis, or foreign body.
One of the most important issues that should be known when planning an operation is the pedicle technique used in the previous surgery of the patient. Secondary breast reduction operations carry the risk for nipple necrosis, and careful planning of the selected pedicle technique is necessary.
A 48-year-old female patient with no systemic disease presented with back pain, recurrent rashes under her breasts, and grooving from bra straps on her shoulders [Figures 1-4]. The patient stated that she had undergone breast reduction surgery with the same symptoms 13 years ago. Although her complaints were fully relieved after the surgery, they repeated and increased during the last 6-7 years. She had gained 18 kg in 13 years. No mass was detected with breast ultrasound and mammography. No information about the patient's previous operation was available. Physical examination of the patient revealed that a vertical-scar breast reduction technique has been applied. Sternal notch to nipple distance on the right breast was 28 cm and on the left breast 29 cm. The nipple inframammary fold distance was 13.5 cm on both sides. She had Grade 3 ptosis according to the Regnault classification.
The patient was scheduled to undergo superior pedicle inverted-T-scar mammoplasty. The new location of the nipple was determined as 24 cm according to inframammary fold distance and arm length. Drawing was done using Wise pattern.
The superior pedicle was created by deepithelialization without any undermining [Figure 5]. Excessive breast and skin were excised in vertical and horizontal planes according to the drawings [Figures 6 and 7]. The incisions were repaired according to the inverted-T-scar technique [Figure 8]. The patient did not experience any complication in 3 months after surgery [Figures 9-12].
In the literature, there are different opinions about the pedicle technique that can be used in secondary breast reduction surgery. Hudson and Skull reported that pedicle technique used in primary operation should be used in secondary breast reduction operation.  They also suggested that if the previous medical records of the patient are not available, a free nipple graft technique should be used. Patel et al. used the same surgical technique in eight patients when the technique of the primary surgery was known and reported a complication rate of 37.5%. In that study, it was emphasized that free nipple graft technique is the most reliable method. 
On the contrary, Losee et al. used pedicle techniques different from those used in primary surgery in 10 patients and reported nipple necrosis in none of the patients.  In the study, they claimed that the secondary breast reduction surgery is a safe operation in terms of nipple circulation regardless of selected pedicle technique.
Evaluation of the nipple circulation is crucial in the planning of the operation. Blood supply of nipple-areolar complex (NAC) is maintained mainly from perforating branches of internal mammary artery. Blood supply comes NAC from the medial side.  If this main circulation is cut during the first operation, then it is not possible to determine the pattern and topography of neovascularization. However, in recent years, nipple-sparing surgery applications in patients who undergo breast reduction or mastopexy surgeries have also shown that secondary breast reduction surgery is safe when performed with appropriate technique. [16,17]
Ahmad et al. described their technique for secondary breast reduction in their study in 2012.  They reported that regardless of the pedicle used in the previous surgery, they did not observe any nipple necrosis when the nipple is elevated up to 5 cm with superior pedicle, vertical elliptical skin, and breast excision technique. They recommend superomedial pedicle technique if nipple elevation exceeds 5 cm. They claim that due to neovascularization, these pedicles are safe and nipple necrosis will not occur if they are formed in 1/1 rate in random pattern and minimal undermining is performed. They considered inverted-T technique and the circulation of medial and lateral flaps that require large undermining unsafe due to previous surgery. We preferred inverted-T-scar reduction technique since nipple inframammary fold distance was 13.5 cm and horizontal skin excess in our patient. We have not met any flap necrosis in our patient. This may be because a long period (13 years) has passed after the first surgery and the neovascularization process has been fully established during this time.
Mistry et al. published a study that can be considered as a guideline in2017.  In this study, they stated that using the same pedicle that had been used in the previous surgery would increase the complications and the same technique should be avoided if a nipple elevation is required. Similar to Ahmad, she suggested the use superior pedicle, inferior vertical wedge skin, and breast tissue excision for nipple elevations up to 5 cm and additional liposuction of lateral excessive tissues. The superior pedicle that Hall-Findlay recommends includes only deepithelialization but not undermining. Unlike Ahmad, Hall-Findlay proposed free nipple graft technique in nipple elevations exceeding 5 cm, while she considered inferior wedge skin and breast excision is sufficient in patients with pseudoptosis. She did not recommend inverted-T technique in these patients by emphasizing that thorax skin can be seen as belonging to breast due to the ptosis and this tissue should not be removed rather restored to its original place on anterior thorax wall. She recommended that the excision should be performed from the proximal end of the current scar in case of horizontal skin excess and in cases where an inverted-T-scar technique should be applied.
Secondary reduction mammoplasty can be performed due to inadequate volume resection in the previous operation, breast deformity, or recurrence of macromastia. When pseudoptosis is the only reason for surgery, inferior vertical skin and breast tissue excision can be sufficient. For nipple elevations up to 5 cm, superior pedicle vertical reduction technique should be used, and for elevations over 5 cm, free nipple graft technique or superomedial pedicle technique should be used. Inverted-T-scar technique is not recommended since this technique requires large undermining and steals from anterior thorax wall; however, if it is required, horizontal skin excision should be performed superior to current scar. We used inverted-T-scar technique due to horizontal skin excess, we planned the excision superior the current scar, and we did not perform large undermining for inverted T-flaps.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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(17.) Alperovich M, Tanna N, Samra F, Blechman KM, Shapiro RL, Guth AA, et al. Nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy: How safe is it? Plast Reconstr Surg 2013;131:962-7.
(18.) Ahmad J, McIsaac SM, Lista F. Does knowledge of the initial technique affect outcomes after repeated breast reduction? Plast Reconstr Surg 2012;129:11-8.
(19.) Mistry RM, MacLennan SE, Hall-Findlay EJ. Principles of breast re-reduction: A reappraisal. Plast Reconstr Surg 2017;139:1313-22.
Department of Plastic Aesthetic Reconstructive Surgery, Balikesir Ataturk City Hospital, Balikesir, Turkey
Address for correspondence: Dr. Bilgen Can, Department of Plastic Surgery, Balikesir Ataturk City Hospital, Altieylul, Balikesir, Turkey.
How to cite this article: Can B. Secondary breast reduction: Outcome and literature review. Turk J Plast Surg 2018;26:180-4.
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|Title Annotation:||Case Report|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Oct 1, 2018|
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