Introduction

Nowadays, symmetrisation procedures of the contralateral healthy breast (reduction mammaplasty, mastopexy and augmentation) are an essential part of postmastectomy reconstructions. They may allow the surgeon to reach the final goal of breast symmetry.

Even though contralateral procedures are performed to improve symmetry, in cases of unilateral implant-based reconstruction, an asymmetry between the two breasts usually occurs over time and it is unavoidable, since the implant and the natural breast parenchyma act differently [1].

At our centre the most frequent procedures on the healthy breast are reduction mammaplasties followed by mastopexies, augmentations are rare. Among different techniques of reduction, relying on different dermo-glandular flaps, skin incisions and suspension sutures, we have observed a different stability of the results over time, depending on the chosen technique itself. In our opinion, these considerations could be of great relevance when planning unilateral implant reconstruction and contralateral breast symmetrisation.

The aim of this study is to evaluate breast symmetry in the long term in cases of postmastectomy unilateral implant reconstruction and contralateral reduction mammaplasty. The secondary endpoint is to evaluate whether different glandular pedicles may better preserve stability over time.

Materials and Methods

Between January 2006 and May 2012, 258 consecutive patients underwent unilateral skin sparing mastectomy, immediate reconstruction with an expander and simultaneous reduction mammaplasty of the healthy breast at our institute. Among them, 98 underwent a superior pedicle reduction [2] (Wise excision pattern), 84 patients a medial pedicle reduction [3] (Wise excision pattern) and 76 patients an inferior pedicled procedure [2] (Wise excision pattern).We included in our study population patients aged between 35 and 65 years old, normal weight (BMI ranging between 18.5 and 24.9 kg/m2), who underwent the same surgical procedure (unilateral mastectomy, immediate reconstruction with a tissue expander and contralateral reduction mammaplasty), with a similar follow-up. Exclusion criteria included BMI < 18.5 kg/m2 and BMI > 24.9 kg/m2, diabetes, chronic liver diseases, coagulopathies, and/or anticoagulant therapy, adjuvant chemotherapy and/or radiotherapy, postoperative complications (haematoma, seroma, implant rotation or displacement, necrosis of the mastectomy flaps or liponecrosis).

So far, according to our criteria, the study population included 101 patients: 37 patients underwent a superior pedicle reduction (GROUP A), 34 women a medial pedicle reduction (GROUP B) and 30 an inferior pedicle procedure (GROUP C). Data from the first 30 patients of each group were analysed for intergroup comparison. Therefore, the final study population consisted of 90 patients (30 women in each study group).

Mean age at surgery was 49 years. Mean weight of the reduction specimen was 295 g (range 180–520).

Tissue expanders were left in place for a mean time of 15 weeks (range 13–19), and replacement with the final prosthesis was performed after a mean period of 19 weeks (range 17–25) (Table 1).

Table 1 Patient demographics, time mammary expanders were left in place, size of final prostheses and mean volume of excised tissue
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Mean volume of the definitive prosthesis was 390 cc (range 240–575). In all patients, anatomical textured silicone gel implants (Mentor) were placed in the sub-pectoral pocket.

The study population was prospectively followed. One month after surgery, an objective evaluation of the reduced breast was performed. Multiple measurements were taken, including the distance between the nipple and lower clavicle margin and the distance between the nipple and the inframammary fold (along the mammary meridian), using an ordinary ruler (Fig. 1). Pictures where collected at 1 month postoperatively. Twenty-four months after the primary surgery, the same measurements of the reduced breast were taken and similar photographic data were collected.

Fig. 1
figure 1

Objective evaluation (1 and 24 months after surgery) based on multiple measurements of the reduced and reconstructed breasts, measured with an ordinary ruler

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Evaluation of the reconstructed breast with the definitive implant was similarly performed at 1 and 24 months after definitive prosthesis implantation. For objective measurements, the point of maximum implant projection (where the nipple–areola complex would presumably be reconstructed after 3 months) was identified and the distances between this point to the inframammary fold and the lower clavicle margin were measured with an ordinary ruler (Fig. 1). Photographic documentation of every reconstructive breast was collected at the 1- and 24-month follow-ups.

Our institutional ethics committee approved the study design. A written informed consent was obtained from all patients in the study.

Statistical Analysis

Intergroup comparison was performed using a one-way ANOVA test, whereas the Tukey’s HSD test was used for the detection of the group causing the difference. P < 0.05 was accepted as the level of statistical significance.

Data were analysed using SPSS version 22.0 (IBM statistics for Windows version 22, IBM Corporation, Armonk, New York, USA).

Questionnaire

Three independent plastic surgeons not belonging to our surgical team were asked to fill in a questionnaire during follow-up visits and/or relying on photographic material (at 1 and 24 months postoperatively). The questionnaires aimed to evaluate the aesthetic outcomes, and they have been used in other studies to assess cosmetics after breast surgery [4, 5].

Five parameters are included in the questionnaire:

  1. 1.

    Shape of the reduced breast not wearing a bra.

  2. 2.

    Symmetry between breasts not wearing a bra.

  3. 3.

    Glandular tissue defects on the reduced breast.

  4. 4.

    Position/distortion of NAC of the reduced breast.

  5. 5.

    Scar quality and/or retraction of the reduced breast.

For each parameter, a 1–4 scale was used for scoring, 4 being excellent, 3 good, 2 sufficient and 1 insufficient. The paired samples Student’s t test was used: P < 0.05 and P < 0.01 were considered significant.

Results

Patients’ demographics are reported in Table 1.

Descriptive results, tests for mean differences and effect sizes specific to the three groups are shown in Table 2.

Table 2 Descriptive data
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Measurements of the reconstructed breast showed similar variations between the 24th and 1st month (Δ) postoperatively in all groups: a mean decrease of 1.1 cm of the distance between the point of maximum projection of the reconstructed breast and the lower clavicle margin (range 0.7–1.6) and a mean decrease of 0.9 cm of the distance between the point of maximum projection and the inframammary fold (range 0.7–1.4) (Fig. 2) (P value  > 0.05 at Tukey’s test).

Fig. 2
figure 2

On the left measurements conducted on the prosthetic breast; this chart shows the similar variations between the 1st and 24th month in all three groups of patients. (Δ IC-MMP: difference between 24th and 1st month of inferior clavicle margin and major projecting point of the mammary cone distance; Δ MMP-IF: difference between 24th and 1st month of major projecting point of the mammary cone and inframammary fold distance). On the right measurements conducted on the contralateral reductive mastoplasty; this chart shows the difference variations between the 1st and 24th month in all three groups of patients: women who underwent reductive mastoplasty using the inferior pedicle had significantly higher reduction in the nipple–clavicle distance as compared to all the other groups and had a significantly higher increase in the nipple–inframammary fold distance. (Δ IC-N: difference between 24th and 1st month of inferior clavicle margin and nipple distance; Δ N-IF: difference between 24th and 1st month of nipple and inframammary fold distance)

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Measurement of the reduced breast showed significant differences within the three groups at the 24th and 1st month (Δ) postoperatively. A mean decrease of 1.5 cm (range 1.2–1.9) of the distance between the nipple and the lower clavicle margin and a mean increase in the distance between the nipple and the inframammary fold of 3.3 cm (range 1.7–3.9) were recorded in GROUP C (inferior pedicle). In GROUP A (superior pedicle), the reduction of the distance between the nipple and the clavicle was 0.8 cm in average (range 0.5–1.3) and the increase in the distance between the nipple and the inframammary fold was 1.6 cm in average (range 1.4–1.9). In GROUP B (medial pedicle), the reduction of the distance between the nipple and the clavicle was an average of 1 cm (range 0.7–1.9) and the increase in the distance between the nipple and the inframammary fold was 2.4 cm in average (range 1.5–3.2). Significant differences exist between GROUP A, B and C with regard to decreased Δ nipple–lower clavicle margin length and increased Δ nipple–inframammary fold length of reduced breasts (P value = 0.01) (Table 3). Patients from GROUP C showed a significantly higher decrease of Δ nipple–lower clavicle margin distance and Δ nipple–inframammary fold compared to GROUP A and B (P value = 0.01) (Table 4).

Fig. 3
figure 3

a–c Preoperative view of a 54-year-old patient who underwent left nipple sparing mastectomy, reconstruction with a tissue expander and contralateral superior pedicled reduction mammaplasty (a). Two-month postoperative view (b). Result at 24 months after left replacement of tissue expander with permanent prosthesis (c). d–f Preoperative view of a 47-year-old patient who underwent left radical mastectomy, insertion of mammary expander and simultaneous reductive mammaplasty (using a medial pedicle) (d). Mammary expander was left in place for 16 weeks (e), and replacement with the final prosthesis was performed after 17 weeks. Postoperative view 24 months after surgery, one month after left nipple reconstruction (f). g–i A 43-year-old patient who underwent right modified radical mastectomy and expander reconstruction and simultaneous inferior pedicled reduction of the healthy breast (g). Six-month (h) follow-up with the right definitive implant in place. Five months after primary surgery, we replace the expander with the definitive prosthesis (i). In these photographs, we can see the “bottoming out” and star-gazing” phenomena: this patient, 6 months after surgery (h), has a nipple–inframammary fold distance of about 6.9 cm and a nipple–lower clavicle margin distance of 21.4 cm; after a period of 24 months (i) the first distance was 9.6 cm (Δ = 2.7 cm) and the second was 19.7 cm (Δ = 1.7 cm)

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Table 3 Intergroup comparison of mean reduction of the distance (in cm) in different groups between 24th and 1st month (Δ) (ANOVA)
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Table 4 Between-group comparisons (Tukey’s HSD test)
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Surgeons’ assessments are shown in Table 5, detailing the average score for every single parameter. There were no significant differences between the three groups: superior versus medial (P = 0.35), superior versus inferior (P = 0.3), medial vs inferior (P = 0.08).

Table 5 Surgeons’ assessments of aesthetic outcomes 2 years after reconstruction with the final prostheses using superior (italics)/medial (bold)/inferior (bolditalics) pedicle
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Higher scores were achieved for question no. 2 (symmetry of the breasts not wearing a bra), no. 3 (glandular tissue defects at the reduced breast) and question no. 5 (scar quality). The lowest scores were regarding question no. 1 (breast shape without a bra).

Discussion

In unilateral postmastectomy implant-based reconstructions, symmetrisation mammaplasties are crucial to achieve final symmetry. Two populations of women are candidates for contralateral mammaplasty: women who undergo surgery on the healthy breast at the same time of immediate reconstruction to improve or fix a pre-existing dysmorphic feature; secondly, women who undergo symmetrisation mammaplasties to achieve symmetry between the healthy breast and the newly reconstructed one [6].

In the first subgroup of patients, surgery of the healthy breast has relevant psychological implications: the achievement of a long wish for aesthetic improvement gives these patients strength and motivation to deal with the long path of breast cancer treatment, with an impressive endurance and sometimes even with a positive attitude [7, 8].

In the second subgroup of patients, surgery of the healthy breast is accepted to achieve satisfactory aesthetic results, and the possibility of histological examination of the reduction specimen is welcomed. Relying on these observations, in our experience we received positive feedback and great acceptance of surgery on the healthy breast, despite the surgical risks and complications inherent to any surgery and the inevitable presence of multiple scars of both breasts.

Surgery of the healthy breast can be suggested with different timing. Some authors believe that both mastectomy and the contralateral symmetrisation should be performed during the same surgery, the reduced breast being the model for the future breast reconstruction once the tissue expander is removed [9, 10]. Others prefer to postpone symmetrisation surgery to when the definitive implant has settled down and has reached its final shape and position. Therefore, it can be used as a guide for the contralateral breast [10].

We do support simultaneous reduction mammaplasty at the time of mastectomy, using the reduced breast as a guide for the implant choice; in fact, our data showed that the reduced breast undergoes significant changes over time, more significant than those occurring in the breast reconstructed with the prosthesis. Therefore, when the expander is removed, the choice of the definitive implant (volume, shape and position) is guided by the previously reduced breast, which has reached its final shape and position in the mean time. It is not possible if mammaplasty of the healthy breast is performed at the same time of expander–definitive implant change. In this case, implant choice may take into account the variables correlated with the healthy and reconstructive breast and it is more challenging.

Among the broad spectrum of surgical techniques for breast reduction [11–13] in cancer patients, the choice should rely on the patient’s oncologic status and expected appearance of the reconstructed breast. The reconstructed mound often significantly differs from a natural breast with regard to morphology (i.e. deficit of projection in the areolar area) and morpho-dynamic characteristics. Patient’s preferences should also be considered with regard to volume, shape and position of the reduced or lifted breast and scar patterns. These factors may affect the choice of skin incisions, the selection of dermo-glandular pedicles for nipple areola complex transposition and the remodelling of the mammary cone.

The choice of different dermo-glandular pedicles should always consider the necessity of removing specific areas of the healthy tissue for diagnostic purposes and the expected final appearance of the reconstructed breast, often characterised by the lack of central projection and a large implant base.

In our study, the Wise pattern was chosen for the reconstructive side in cases of large and ptotic breasts requiring extensive skin reduction. It allowed an improvement of the final shape of the reconstructed mound, mimicking a reduced breast.

Our data confirm that different dermo-glandular pedicles result in different levels of stability of the breast shape over time. Previous studies have demonstrated that the reduction technique influences the durability of the aesthetic outcomes [12, 14, 15]. In our series, a gradual significant increase in the distance between the areola and the inframammary fold (bottoming-out effect) was maximum in GROUP C (inferior pedicle) and minimum in GROUP A and B (respectively, superior and medial pedicles). Thus, the superior–medial pedicles show better long-lasting results (see Fig. 3).

Although inferior pedicled mammaplasties are very popular [16], the technique is frequently associated with “bottoming out” (pseudoptosis) and “star-gazing” (upward rotation of the nipple–areola complex) phenomena [14]. Surgical tricks have been developed to solve the problem, including the internal suspension of the inferior pedicle, dermal flaps, fascial and muscular flaps [14–18]. If no restriction exists in the choice of the glandular pedicle (i.e. not too ptotic breasts or the necessity of glandular removal in the upper quadrants), our findings should be taken into consideration, given that the contralateral breast is reconstructed with an implant and sagging is therefore an unlikely occurrence.

On the contrary, superior or medial pedicled reduction mammaplasties seem to better maintain shape and position over time and therefore look more similar to the contralateral prosthetic breast. A lower incidence of glandular ptosis was recorded in our series. This is probably due to the possibility of having a solid parenchyma structure thanks to multi-layered sutures of the mammary pillars, the “hammock” technique or an inferiorly based dermal adipose flap [14–18]. In our hands, we could not reach the same result by performing inferior pedicled techniques and their variations.

With regard to cosmetic outcomes, good aesthetic results and surgeons’ satisfaction were achieved in the three groups. The surgeons’ assessments (at 2-year follow-up) showed no statistically significant differences between the groups (P > 0.05). However, the lowest scores were recorded for question no. 1 (breast shape without a bra) and no. 4 (position of nipple areola complex of the reduced breast) in GROUP C (inferior pedicle); it was probably due to the “bottoming out” and “star-gazing” phenomena.

The surgeons’ overall satisfaction rate was higher, but not significantly, for GROUP A and B in comparison with GROUP C.

Limitations of the Study

This study has some limitations to point out.

No preoperative measurements of the healthy breast exist to objectively evaluate the grade of ptosis. We do expect that more ptotic breasts have been corrected using inferior pedicled techniques and the initial grade of ptosis may influence ptosis relapse per sé.

The sample population is small, and we are enrolling more patients who are prospectively followed.

BMI variations in the study population have not been recorded. It is quite common for patients to gain weight during and after cancer treatment, and it could have biased the results. A study including only patients with a constant BMI during follow-up is necessary to confirm our conclusions.

Furthermore, the follow-up is limited at the 24-month assessment. Larger series with longer follow-up are needed to validate the long-lasting technique of breast reduction.

Conclusion

Our series demonstrated that the reduced breast undergoes significant modifications in shape and position over time. They are more significant than those occurring in the reconstructed breast mound with an implant. Therefore, the idea to use the reduced healthy breast as a guide for implant choice represents an adequate motivation to support mastectomy and simultaneous reduction. Techniques using a superior or medial pedicle seem to better preserve the shape and position over time, with an appearance similar to reconstructed breast.