The Pedicled Robertson Reduction Mammaplasty: A Safe Option for Gigantomastia
Richard Restifo, M.D..
Yale New Haven Hospital, New Haven, CT, USA.
BACKGROUND: Patients with severe macromastia pose specific challenges. A time-honored approach to these large reductions has been the amputation/free-nipple graft technique. However, the main disadvantage to this method relates to the the quality of the grafted nipple-areolar complex; lack of sensibility and erectile function, failure of lactation, and limited projection are the norm, and loss of pigmentation is not uncommon. Another option for gigantomastia is the inferior pedicle reduction mammaplasty. However, the marginal vascularity at the inverted-T junction leads to a high minor wound complication rate in this area; minor dehiscence, flap epidermolysis and hypertrophic scarring are common. Another concern is the "bottoming" of the lower pole that is common over time with the inverted-T inferior pedicle reduction mammaplasty.
A method that lends itself to the treatment of severe macromastia is the Robertson mammaplasty, described in 1967 as a free-nipple graft but later modified to transpose the nipple-areolar complex on an inferior pedicle. The characteristic feature of this mammaplasty is a "bell-shaped" inferiorly based skin flap that preserves the lower pole of the breast and serves as the base for the deepithelialized pedicle, which commences several centimeters above the inframammary fold. This in essence shortens the length of the inferior pedicle and avoids a vertical component to the skin closure. The scar configuration is thus absent the trifurcation with its propensity for wound breakdown. Aesthetic advantages to this inferior skin flap are the interposition of central lower pole surface area, ameliorating the "boxiness" that is common in large reductions, as well as the preservation of the inframammary fold, which may prevent the tendency towards "bottoming". This abstract reports on the author's experience in using the Robertson mammaplasty for reductions of greater than 1500 grams per side.
METHODS: The author's breast reduction caseload over a five year period was examined. Cases were identified that underwent reductions of greater than 1500 grams per side using the Robertson reduction technique. Eighteen patients met these criteria and their charts were retrospecively reviewed. All surgeries were performed by the author with the help of a physician's asssistant.
RESULTS: The average resection was 1856 grams per side and the average sternal notch to nipple distance was 38.7 cm. There were no anaesthetic complications. There were no cases of partial or full nipple-areola loss, no hematoma, no flap necrosis or epidermolysis. One patient had hypertrophic scarrring. Four patients had minor areas of parenchymal fat necrosis.
CONCLUSIONS: The Roberston Mammaplasty is an underutilized method for the treatment of gigantomastia. This technique offers efficiency, relative freedom from major and minor complications, and good aesthetic results.
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