Keywords two-flap technique - breast reduction surgery - upper pole fullness - breast aesthetics
Introduction
The standards of modern plastic surgery, as articulated by Jack Penn 65 years ago,
assert that enlarged breasts must be reduced to normal proportions while achieving
both symmetry and aesthetic appeal. These foundational principles remain critical
in contemporary practice, particularly as an increasing number of older women seek
breast reduction surgery to alleviate functional discomfort and enhance aesthetic
outcomes. Traditional methods, while effective in reducing breast volume, often fall
short in addressing the long-term maintenance of breast shape and projection, particularly
in patients of advanced age.
Historically, plastic surgeons have focused solely on nipple position during reduction
mammoplasty and very little importance has been given to breast aesthetics. Photographic
analysis reveals that conventional breast reduction techniques produce a linear and
sometimes a concave upper pole contour.[1 ] The deflation of upper pole of breast following various conventional breast reduction
techniques has always been a concern. Such concern was cited by Graf et al in 2000
in which she attempted to pass a dermoglandular chest wall flap under the pectoralis
muscle loop in an attempt to regain upper pole fullness. Although Graff described
a method involving the placement of the pedicle beneath a pectoralis muscle sling,
our technique introduces unique aspects that have not been addressed in the existing
literature.[2 ] Swanson in 2014 published a technique of breast reduction with the use of breast
implants to achieve upper pole fullness.[1 ] But the simultaneous use of breast implants in breast reduction has been a matter
of concern for various plastic surgeons all over the world.
Emerging research indicates that achieving high patient satisfaction in breast reduction
surgery requires a dual focus on both volumetric reduction and aesthetic enhancement.
The two-flap technique represents a significant advancement in this regard, designed
to tackle common challenges associated with traditional approaches. By creating two
distinct flaps from the upper and lower poles of the breast, and using the lower central
pedicle as retro glandular (RG) flap, this technique provides better upper pole fullness
and enhanced breast aesthetics.
Studies have highlighted the need for innovative techniques in breast reduction to
improve aesthetic outcomes while reducing complications. In 2000, Graf pioneered a
technique to enhance upper pole fullness by positioning a dermo glandular chest wall
flap beneath a pectoralis muscle loop.[2 ] Similarly, in 2012, Widgerow introduced a dermal fascial suspension method, creating
an “internal bra” effect to stabilize breast shape and projection.[3 ] These advancements illustrate the continuous evolution in breast surgery, demonstrating
how innovative techniques increasingly align with both aesthetic and functional patient
needs.
This article aims to present the theoretical framework, surgical methodology, and
early clinical outcomes associated with the two-flap technique. Our primary objective,
however, is to enhance aesthetic outcomes; by focusing on enhancing upper pole fullness
and overall breast contour, this approach has the potential to improve patient satisfaction
and deliver superior long-term results. Through this exploration, we seek to contribute
to the ongoing advancements in breast surgery, emphasizing the significance of the
two-flap technique in addressing the evolving demands of patients.
Materials and Methods
A total of 165 patients from a retrospective cohort underwent breast reduction surgery
utilizing the specified technique between February 2022 and February 2024. The study
is approved by the GeneBandhu Ethics Committee (Ref- ECG030/2024); the meeting was
held on October 16, 2024.
The methodology includes a comprehensive overview of the preoperative assessment and
the specific steps of the surgical technique employed during breast reduction surgery.
Marking
Skin marking is done preoperatively in the standing position. Standard breast landmarks
are drawn including the sternal notch, chest midline, inframammary fold (IMF), and
breast meridian. The arms may be raised to help delineate the lateral border of the
breast in those with a significant excess lateral chest tissue. The Pitanguy's point,
or the anterior projection of the IMF into the breast meridian, is marked by direct
palpation or using a flexible ruler positioned under the breast. New nipple–areola
complex (NAC) is planned over Pitanguy's point marking a circle of circumference 16 cm.
5 cm long vertical limbs are marked from the new NAC marking. The opening of this
5-cm triangle or the angle between the vertical limbs depends upon the amount of skin
and breast tissue excision needed. Breast tissue is displaced superomedial to mark
lateral IMF. Similarly, breast tissue is displaced superolaterally to mark medial
IMF. The vertical limbs are then connected to the medial and lateral IMF marking with
smooth, curvilinear lines.
The first pedicle (superior pedicle) is marked starting superiorly from the new NAC
location, extending inferiorly forming a smooth U around the NAC, and terminating
at the junction of junction of the new NAC with the vertical limb marking. The second
pedicle (central pedicle) is marked with an approximate width of 8 cm over the breast
meridian starting from the IMF and moving upwards till NAC ([Fig. 1 ]).
Fig. 1 Markings for breast reduction.
Surgical Technique
A breast tourniquet is applied. Using an areolar marker of 44 mm, incision is marked
over NAC and both pedicles are de-epithelialized ([Fig. 2 ]).
Fig. 2 Dissection between flap 1 and flap 2.
The superior pedicle (carrying the NAC) is created using the cautery to dissect straight
down to the chest wall. Dissection is done with electrocautery in a perpendicular
direction between the pedicles ([Fig. 3 ]).
Fig. 3 Flap 2 dissected along with lateral and medial breast tissue to be resected.
The inferior breast tissue which also includes the second or central pedicle is a
block of parenchyma of the lower pole of the breast. On all four sides, dissection
is carried down to the pectoral fascia so that the block of tissue is totally mobile.
The whole breast tissue from the lateral to inferior and then to medial extent is
dissected till the pectoral fascia along with the central flap ([Fig. 4 ]). Skin flap of approximate 1 cm thickness is elevated from medial and lateral aspects
of the marking. Skin flap thickness at the inferior aspect is kept thinner than 1 cm,
as it helps in skin re-draping at the time of skin closure.
Fig. 4 Excision of tissue lateral and medial of inferior flap 2.
Out of this whole breast tissue dissected, we remove the breast tissue medial and
lateral to de-epithelized second flap, also called as central pedicle flap. This flap
is based on thoracic wall perforators ([Fig. 5 ]).
Fig. 5 Dissecting pocket beneath flap 1/ superior flap.
A pocket is created under the superior pedicle (flap carrying the NAC) above the pectoral
fascia up to second intercostal space ([Fig. 6 ]). The second flap of dermo glandular tissue based on central pedicle is propelled
under the superior breast tissue (the first flap) as RG flap and fixed to pectoralis
fascia with a nonabsorbable suture (Nylon 1–0). Three to four sutures are used to
fix the second flap at the upper pole opposite the second intercostal space ([Fig. 7 ]).
Fig. 6 Fixation of inferior Retroglandular flap (RG) under superior flap opposite second
intercostal space.
Fig. 7 Creation of neo, IMF, Inframmamary fold.
The superior-most point of the vertical limbs is closed with a “2-0 PDS suture” followed
by closure of vertical limbs of medial and lateral pillars. Usually, three to four
sutures are used to close the pillars. New IMF is created usually at a distance of
7 to 8 cm from the NAC by suturing the lateral and medial neo-inframammary fold skin
to pectoral fascia. Remaining skin incision is closed above in further two layers,
Stratafix No. 1 in subcutaneous, followed by subcuticular 3–0 Monocryl ([Fig. 8 ]).
Fig. 8 Comparison of both breasts on OT table.
Deep dermal sutures (PDS 2–0) are then used at the 12, 3, 6, and 9 o'clock positions
of the NAC to set the NAC position. The remaining skin incisions around NAC is closed
with 3–0 Monocryl subcuticular. No. 18 suction drains are used only in selected patients
with large reductions leaving substantial dead space that required drainage. Drains
were removed once the drainage was less than 30 mL/day. All patients had their drains
removed within 48 hours.
Data collection encompassed demographic details, final diagnoses, the volume of tissue
reduced (in grams), and postoperative outcomes, including the occurrence of seromas,
wound dehiscence, and patient satisfaction. Follow-up evaluations were regularly conducted
up to 6 months, with additional follow-ups scheduled as necessary for any complications
reported ([Figs. 9 ] and [10 ]).
Fig. 9 Comparison of both breasts on OT table. One can appreciate the upper pole fullness
and cleavage achieved on OT table on reduced Rt breast. OT, operating table.
Fig. 10 Before and after surgery of a breast reduction surgery patient using the two-flap
technique. Comparison of both breasts on OT table. OT, operating table.
Results
The analysis of patient data from the study provides valuable insights into demographics,
surgical outcomes, and satisfaction levels. The largest age group (66.67%) was between
31 and 40 years, followed by 21.21% of patients aged 21 to 30, and 12.12% in the 41
to 50 range. The mean age was 34.59 years, with a range of 21 to 50 years ([Table 1 ]).
Table 1
Distribution of respondents
Category
Number of patients (n = 165)
Age group (years)
21–30
35 (21.21%)
31–40
110 (66.67%)
41–50
20 (12.12%)
Mean ± SD (range)
34.59 ± 5.7 (21–50)
Amount of reduction (g)
200–400 g
80 (48.49%)
400–600 g
55 (33.33%)
600–800 g
30 (18.18%)
Presence of seroma
No
153 (92.73%)
Yes
12 (7.27%)
Presence of wound dehiscence
No
159 (96.36%)
Yes
6 (3.64%)
Regarding marital status, 92.73% of patients were married, while 7.27% were unmarried.
Tissue reduction analysis showed that nearly half of the patients had a reduction
of 200 to 400 g, one-third had 400 to 600 g removed, and the remaining patients experienced
a reduction of 600 to 800 grams.
Post-surgical outcomes were favorable, with 92.73% of patients not experiencing seroma,
and 7.27% reporting its occurrence. Wound dehiscence occurred in 3.64% of cases.
Patient satisfaction was exceptionally high, with 89.09% rating their experience as
“highly satisfied” and 9.69% as “satisfied,” indicating the procedure's success in
both medical outcomes and patient experience ([Table 2 ]). Satisfaction was measured using a 5-point Likert scale.
Table 2
Satisfaction level of the patients
Satisfaction level
Number of patients (n = 165)
Percent (%)
Highly satisfied
147
89.09
Satisfied
16
9.69
Neutral
1
0.61
Dissatisfied
1
0.61
Highly dissatisfied
0
0
Discussion
The present analysis provides valuable insights into patient demographics, surgical
outcomes, and satisfaction levels, laying a foundation for evaluating the efficacy
of the two-flap technique in breast reduction surgery. This technique has emerged
as an innovative approach that offers distinct advantages over traditional methods,
particularly in terms of aesthetic outcomes, minimizing complications, and enhancing
patient satisfaction. By addressing key challenges such as upper pole deflation and
visible scarring, the two-flap technique offers both functional and aesthetic improvements,
which align with the principles of modern plastic surgery.
Maintaining upper pole fullness is a critical determinant of postoperative breast
aesthetics. The two-flap technique 's innovative use of two distinct flaps of breast
tissue—specifically, the superior pedicle flap for preserving the vascularity of the
NAC and the central breast mound RG flap to enhance upper pole fullness—effectively
addresses this challenge. The dual-flap approach contributes to a more rounded, aesthetically
pleasing breast shape, a factor known to be crucial for long-term patient satisfaction.
Existing literature, including studies by Gusenoff et al and Swanson, emphasizes the
importance of upper pole fullness in achieving desirable breast aesthetics.[4 ]
[5 ] These studies reinforce the findings of this analysis, indicating that techniques
that preserve upper pole contour and projection are essential for maintaining breast
shape and overall satisfaction in the long term.
The low complication rates observed in this study further underscore the advantages
of the two-flap technique. Wound dehiscence just accounted for only 3.64% of the total,
while seroma formation was noted in 7.27% of cases. These findings are particularly
notable when compared with traditional breast reduction methods, where complication
rates tend to be higher. The meticulous surgical technique, careful intraoperative
management, and comprehensive postoperative care protocols appear to have contributed
to these favorable outcomes. The results align with previous studies such as Pusic
et al and Coriddi et al, which highlight the role of advanced surgical techniques
in reducing complication rates.[6 ]
[7 ] The remarkably low incidence of seroma and wound dehiscence in our study supports
the argument that the two-flap technique represents a significant improvement over
conventional approaches in terms of patient safety and recovery.
High patient satisfaction further highlights the effectiveness of this technique.
In our study, 98.78% of patients expressed high satisfaction with their results. This
positive feedback reflects the combined impact of improved aesthetic outcomes and
functional benefits. Hidalgo noted that both functional improvements, such as relief
from macromastia symptoms, and aesthetic enhancements play a significant role in patient
satisfaction.[8 ] The two-flap technique 's ability to address both aspects accounts for the satisfaction
observed in this study.
Compared with traditional methods, which often struggle to maintain upper pole fullness
and tend to leave more visible scars, the two-flap technique offers clear advantages.
The strategic design of this technique ensures better upper pole support using the
RG flap, effectively addressing common concerns among patients seeking breast reduction
surgery. Studies by Chang & Cheng and Tebbetts support the need for innovative techniques
that prioritize both aesthetic and functional outcomes.[9 ]
[10 ] By overcoming the limitations of traditional approaches, the two-flap technique
aligns with contemporary trends in plastic surgery, where achieving long-term aesthetic
stability without compromising function is paramount.
The findings from this study provide strong evidence supporting the clinical efficacy
of the two-flap technique in breast reduction surgery. The technique's ability to
maintain upper pole fullness, minimize complications, and deliver high patient satisfaction
makes it an attractive option for surgeons and patients alike.
Future research may further explore the long-term sustainability of these results
and compare them across diverse patient populations to reinforce the broader applicability
of the two-flap technique in clinical practice.
Conclusion
The two-flap technique for breast reduction surgery represents a significant advancement
in addressing critical challenges such as upper pole fullness and overall breast contour.
The low complication rates and high patient satisfaction further validate the efficacy
of this approach. However, it is important to note that this technique may be less
effective for patients with larger breast sizes.
Moving forward, we believe that ongoing refinement of the two-flap technique, along
with comprehensive long-term follow-up studies, will be essential in establishing
it as a standard practice in breast reduction surgery. By further investigating its
outcomes and patient experiences, the surgical community can ensure that this technique
continues to meet the evolving needs of patients, ultimately improving their quality
of life and satisfaction with surgical results.
