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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1362-1368

Evaluation of septum-based reduction mammaplasty


1 Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Anatomy, Faculty of Medicine, Menoufia University, Menoufia, Egypt; Department of Anatomy, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

Date of Submission22-Feb-2017
Date of Acceptance23-Apr-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Ahmed F Elborgy
Tanta, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_143_17

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  Abstract 


Objectives
The aim of this study was to evaluate the technique of septum-based reduction mammaplasty regarding safety, esthetic results, and patient satisfaction.
Background
Improved understanding of anatomy and continuous evolution in surgical techniques helped to shift the focus from simple reduction surgery to keeping long-lasting esthetic results. The present study evaluated the reduction mammaplasty based on the fixed anatomical structure called Würinger's septum which carries the main nerve and blood supply to the nipple.
Patients and methods
This study included 30 patients experiencing macromastia who visited the outpatient clinic of Department of Plastic Surgery, Menoufia University Hospital, from April 2015 to December 2016, and they underwent septum-based reduction mammaplasty based on Würinger's septum. Overall, 16 medial and 14 lateral septum-based pedicles were designed according to each patient characteristics. The patient characteristics, operative data, and results of the work were recorded.
Results
Septum-based reduction mammaplasty was done for 30 patients, with an age range of 29–56 years. The mean nipple to sternal notch distance (suprasternal notch to nipple) was 31 cm, with range of 27–40 cm. The mean distance of nipple–areola complex elevation was 12 ± 2 cm, with range of 6–18 cm. The mean weight of tissue resection was 638 ± 22 g. The mean operative time was 101 min (range: 85–119 min) in reduction-only procedures and 146 min (range: 125–185 min) with those requiring additional procedures. No major complications were recorded.
Conclusion
Septum-based mammaplasty is a safe and reliable breast reduction technique. It preserves the nipple sensation more than other mammaplasty techniques, and also major complications can be avoided.

Keywords: breast, reduction mammaplasty, septum


How to cite this article:
Kishk TF, Elsakka DM, Elakabawy GF, Nassar AT, Elborgy AF. Evaluation of septum-based reduction mammaplasty. Menoufia Med J 2018;31:1362-8

How to cite this URL:
Kishk TF, Elsakka DM, Elakabawy GF, Nassar AT, Elborgy AF. Evaluation of septum-based reduction mammaplasty. Menoufia Med J [serial online] 2018 [cited 2024 Mar 28];31:1362-8. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1362/252023




  Introduction Top


Reduction mammaplasty is a commonly performed plastic surgical procedure. The American Society of Plastic Surgeons reported that 41 309 breast reductions and 59 883 reconstructive breast reductions were performed in 2014[1].

Numerous techniques for breast reduction have been described. Each of them has its pros and cons. It is difficult to blame a specific pedicle as the only reason for complications and unfavorable results in reduction mammoplasty. The results depend on many factors such as skin quality, age, history of smoking, comorbidities, patient expectations, severity of ptosis, and surgeon's experience[2]. Reduced nipple–areolar complex (NAC) sensation was a common problem after several breast reduction techniques[3],[4]. This drawback was a motive to look for a technique that is safe and reliable regarding the blood and nerve supply of the NAC. So the septum-based pedicle reduction mammaplasty using the breast septum as a fixed anatomical structure, which was described by Würinger, was chosen to be done for the cases in this study.

Anatomy

The breast septum is a thin horizontal fibrous septum, originating from the pectoral fascia along the level of the fifth rib, heading toward the nipple. This septum lies in between a cranial (thoracoacromial and lateral thoracic vessels) and a caudal (intercostal and internal thoracic arteries perforators) vascular network as well as the deep and superficial branches of fourth to sixth lateral intercostal nerves[5],[6]. It forms vertical ligaments at its medial and lateral border [Figure 1]. The medial vertical ligament is strong and attached to the sternum at the level of the second to the fifth rib, whereas the lateral vertical ligament is a weak fibrous structure that emerges from the pectoralis fascia at the lateral edge of pectoralis minor[7].
Figure 1: The Würinger's horizontal septum attaching the nipple-areola complex to the thoracic wall at the level of the fi fth rib. Quoted from, Hamdi M, Hmmond D, Nahai F, eds. Vertical Scar Mammaplasty. New York: Springer Verlag Berlin Heidelberg, 2004. {3}.

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The principal steps in this technique are as follows. (a) The choice of septum lateral or medial pedicle was decided according to the need of each patient: septum medial pedicle in older patients, marked low nipple position, or excess fullness in lateral aspect of the breast, whereas lateral septum pedicle in younger patients, excess fullness in the medial aspect of the breast, or patients with special demand of keeping the nipple sensation[8]. (b) Glandular wedge resection is done caudal to the septum in the lower pole of the breast, and C-shaped resection is done cranial to the septum around the pedicle. (c) In lateral septum-based reductions, suturing of the lateral pillar to the pectoralis fascia is done to avoid lateral fullness of the breast[9]. (d) Closure pattern is adjusted according to each case after completion of excess breast tissue resection[7].

The aim of this study is to evaluate the septum-based mammaplasty technique regarding safety and esthetic results.


  Patients and Methods Top


The study was approved by the Ethical Committee of Menoufi a Faculty of Medicine and informed consent was obtained from each patient. This prospective study was done at the Plastic Surgery Department of Menoufia University Hospital from April 2015 to December 2016. Overall, 30 patients with symptomatic macromastia who visited the plastic surgery outpatient clinic in stable medical conditions, with no exclusion criteria, with age range of 29–56 years, were operated on using the septum-based NAC pedicle. Patients excluded from this study were those with history of previous reduction mammoplasty, breast cancer, breast reconstruction surgeries, psychological instability, unrealistic expectations, and medically unfit. Informed consent was taken for every patient.

Preoperative markings

Important landmarks considered included the midline, breast meridian, inframammary fold (IMF), and suprasternal notch–nipple line, and then the new nipple position was determined. The periareolar figure was then drawn with a circumference of 14–16 cm [Figure 2].
Figure 2: The preoperative marking in standing position (1-3),with lateral septum based pedicle marked (4 and 5) and the lower pole wedge is marked.

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Surgical procedure

Anesthesia

General inhalation anesthesia with endotracheal intubation was initiated.

Patient positioning

Patients were placed in a supine position, with elevation of the upper half of the table at 30° and arms abducted 90°.

Lower pole wedge resection and exposure of the caudal end of the septum

After tissue infiltration and de-epithelialization of the pedicle, resection of the lower pole of the breast tissue started about 6 cm from the points B and D above to the point where the medial and lateral resection markings meet 2 cm above the IMF below [Figure 2], dissection was completed to the prepectoral fascia, at this point the caudal end of the septum could be visualized showing the blood vessels running towards the nipple [Figure 3].
Figure 3: Lower pole wedge re sected (1), Deepithelialzation of the pedicle (2), and vessels are shown running in the caudal surface of the septum (3)

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Pedicle dissection and C-shaped glandular resection

According to the decision regarding a medial or lateral septum-based pedicle, a C-shaped resection of the beast tissue was done around the pedicle which remained attached to the pectoral fascia by the septum [Figure 4].
Figure 4: The C resection of the glandular tissue (1) and the cranial aspect of the septum is shown (2).

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Septum-based medial pedicle

The gland tissue was incised lateral and superior to the pedicle by sharp dissection in the superficial 2 cm of tissue and then bluntly down to the pectoral fascia keeping the central and medial attachment of the pedicle to the septum with base width 8–10 cm; special care was taken in performing the lateral dissection to avoid injury of the deep branch of lateral fourth intercostal nerve by leaving the prepectoral fascia intact. Upper pole blunt dissection to the retromammary space exposed the cranial surface of the septum. The septum medial pedicle was decided for cases with older age, excess low nipple position with higher risk of NAC-impaired blood supply, and excess lateral breast tissue to be resected.

Septum-based lateral pedicle

The glandular tissue was incised medial and superior to the pedicle in a similar way to the medial pedicle. An additional anchoring suture, fixing the lateral pillar to the pectoral fascia at the breast meridian just below the caudal surface of the septum, was done to maintain the lateral contour of the breast, avoid lateral displacement, and help flap rotation without tension. It is important to mention that the septum was found in all cases included in this study regardless of the age or the degree of ptosis.

Closure of the incision

The pedicle was sutured with one 2/0 vicryl suture to the new periareolar breast tissue at 12 o'clock position. The medial and lateral pillars were approximated together by 2/0 vicryl sutures, and then subcutaneous 3/0 polydioxanone was used to close subcutaneous tissue in the periareolar wound [Figure 5].
Figure 5: Closure of the periareolar and vertical limb wounds in layers (1-4).

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Liposuction

Liposuction of lower pole was done in case of asymmetry, lateral fullness, and for more IMF definition.

Postoperative care

Close observation was made of the NAC viability, drains collection, and on discharge. Patients were instructed to keep wearing the pressure garment for 4 weeks and received the postoperative medications (e.g., pain killers). Follow-up appointments were done.

Statistical analysis

All data were collected, tabulated, and statistically analyzed using SPSS (19.0 for Windows; SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean and SD. Qualitative data were expressed as number and percentage. Parametric tests such as t-test were used when data followed or were being transformed to normal distribution. Nonparametric tests such as χ2 were used when data did not follow normal distribution. P values were considered significant if less or equal to 0.05.


  Results Top


This study included 30 patients experiencing macromastia between April 2015 and December 2016.

The patients' age ranged between 29 and 56 years, the mean age was 44.5 years. The BMI was 32.8, with range of 26–42.8.

The main complaints of the patients were ptosis and unhappiness of the breast shape in 23 (83.3%) cases and breast heaviness in 18 (60%) cases. Other complaints were neck and back pain 15 (50%) cases, bra-line grooving in 12 (40%) cases, shoulder pain in 10 (33.3%) cases, and contact dermatitis in 5 (16.7%) cases. It was noticed that all cases complained of more than one single symptom.

Regarding the assessment of the size of the breast and the degree of ptosis, we used the suprasternal notch to nipple distance. This distance ranged between 27 and 40 cm, with mean of 31 cm [Table 1]. All patients were subjected to breast reduction using septum-based technique with excision of either the lateral or medial quadrant depending on the choice of the pedicle.
Table 1: Patient's characteristics

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There was no relation between the pedicle choice, either medial or lateral septum-based pedicle, and the closure pattern, which included vertical closure in 13 (43.3%) cases, inverted T in 15 (50%) cases, and J-closure in two (6.7%) cases [Table 2].
Table 2: Operative data

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The mean weight of resected tissue was 638 g, with range of 280–970 g per breast. The mean distance of nipple elevation was 10 cm, with range of 5–18 cm.

The mean operative time in reduction mammaplasty alone (18 cases) was 101 min, with range of 85–119 min. The operative time was longer (mean: 146 min; range: 125–187 min) in the cases where additional procedures were done, as in 12 (40%) cases, (liposuction three cases, lateral chest folds liposuction four cases, brachioplasty two cases, abdominoplasty one case, and gluteal fat transfer in two cases) without affecting the outcome.

Regarding the touch sensation of the NAC after surgery, we found decrease in touch sensation of the nipple in the first 3 months postoperatively in both medial and lateral septum-based cases. It improved to 75% (of the preoperative nipple sensation) in medial septum-based cases and 95% in lateral septum-based cases at 6 months postoperatively, with significant difference in favor of the lateral septum pedicle [Table 3].
Table 3: The nipple sensation changes after surgery in medial and lateral septum-based cases

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The postoperative complications were unpleasant scar in 15 (50%) cases, persisted diminished sensation of the nipple in two (6.7%) cases, and partial wound dehiscence in two (6.7%) case, which were treated conservatively by dressing [Table 4].
Table 4: Postoperative complications

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Every patient (6 months postoperatively) was asked to answer a patient satisfaction questionnaire and give a score from 1 (very disappointed) to 10 (very pleased) regarding each of the following item: the new breast size, breast shape, breast symmetry, scars, nipple sensation, symptom relief, bra and clothing fitting, esthetic results, and overall satisfaction; (pre and post-operative cases of medial septum pedicle [Figure 6] and lateral septum pedicle [Figure 7]) were demonstrated. This revealed high overall satisfaction rate up to 89% ([Table 5] and [Figure 6] and [Figure 7]).
Figure 6: A pre and 9 months' post-operative photo of acase of a 37 years old patient after medial septum based reduction mammoplasty (SSN–N) distance 39 cm in both sides, NAC was elevated 16 cm, with resection of 970 gm from right and 910gm from left were removed.

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Figure 7: A pre and 6 months post operatively of a 47 years old lady after lateral septum based reduction mammoplasty with (SSN-N) distance 30 cm, removal of 370 gm and 335 gm from right and left side respectively.

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Table 5: Patient satisfaction questionnaire

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  Discussion Top


Vertical reduction mammaplasty, which is a widely used procedure, provides good esthetic results as described by Lejour[10],[11], but complications are frequent with this technique. The most common defects include difficulty in pedicle folding in fibrous breasts, and also flap thinning to help folding is risky for blood supply of NAC[4]. Inferior pedicle reduction solved the problem of positioning the pedicle, but bottoming out is a common drawback[12].

The concept of medial or lateral pedicle was adopted by many authors. Skoog was the first to publish regarding the lateral dermoglandular pedicle[13],[14],[15]. Hall-Findlay[16] described vertical mammaplasty by using superomedial pedicle with resection extended to the level of the pectoral fascia, but without inclusion of the horizontal septum.

None of the aforementioned techniques relied on specific anatomic structures or on well-established blood and nerve supply. On the basis of anatomical studies done by Würinger and colleagues, concerning the blood and nerve supply to the breast and NAC, septum-based reduction mammaplasty was used to meet the requirements for an optimized safe technique and to improve long-term esthetic results.

In this study, medial septum-based pedicle was chosen in 16 cases and lateral septum in 14 cases. Medial septum-based pedicle was chosen for cases with excess fullness in the lateral breast tissue and in cases with marked low positioned nipple, whereas lateral septum-based pedicle in cases with excess medial fullness of the breast tissue and moderate low nipple position, and the results were similar to pedicle choice in the study by Hamdi et al.,[7] where they did lateral septum-based pedicle in cases with moderate ptosis and excess medial breast tissue and medial septum-based pedicle in cases with marked ptosis and excess lateral breast tissue[5].

Ryssel et al.[2] used the craniomedial septum-based pedicle to retain perforators of the internal thoracic artery. Laterally they did limited dissection to preserve the deep lateral branch of the fourth intercostal nerve which runs from lateral to medial below the prepectoral fascia[2].

In this study, the mean distance of nipple elevation was 10 cm (6–18 cm). This was similar to the study by Hamdi et al. where nipple elevation range was 9 cm (3–17 cm)[5] and study by Ryssel et al.[2] where it was 9.5 cm (5–17 cm).

The closure pattern included short inverted T in 15 (50%) cases, vertical in 13 (43.3%) cases, and J-closure in two (6.7%) cases. The short inverted T was preferred to the vertical pattern with puckered skin to minimize the revision rate because ~20% vertical reductions need a scar revision in the caudal part of the vertical scar according to Hall-Findlay[16].

Hamdi et al.[7] used vertical pattern in 60.8%, inverted T closure in 20.6%, and J shaped in 18.6% of the cases. The choice by Ryssel et al.[2] was the inverted T closure for all cases, which may be because of the unwillingness to wait for the vertical wound pucker to resolve with time.

In this study, reduction mammaplasty was simultaneously done with other procedures in 12 (40%) cases. Stevens et al.[17] found that combination of cosmetic surgical procedures did not increase morbidity, and the potential benefits of combined procedures (a single recovery period, reduced surgery costs, and faster patient gratification) may be considered.

In this study, the mean operative time was 101 min, with range of 85–119 min. Stevens et al.[18] in their study found the mean operative time for inferior pedicle reduction to be 115 min, with range of 50–195 min. This difference can be explained by the fact that septum preservation as a constant anatomical structure carrying fixed blood and nerve supply to the NAC helps dissection and removal of the excess breast tissue.

No major complications (total or partial nipple areola necrosis, hematomas formation, or flap necrosis) were found. Minor complications included the following: 50% of cases were unhappy with the scar but did not considered it to be a problem and did not ask for scar revision, superficial wound dehiscence developed in two cases, and two cases experienced persistent diminished nipple touch sensation. Ryssel et al.[2] did not state any major complications, and they did scar revision in three cases. Hamdi et al.[7] had one case of total nipple loss, which was a case of diabetes and heavy smoker, and three cases of hematoma.

Carpelan et al.[19] noted in a study of 110 (6%) inferior pedicle reduction surgery patients that major complications were deep infections, wound dehiscence of more than 2 cm (5%), and hematomas (5%). Partial necrosis of the NAC occurred in 4.5% and total necrosis in 3.6% of the cases. Minor complications included delayed healing in 45% and superficial infections in 15%.

In this study, touch sensation of the nipple was impaired in the early postoperative period (3 months) which then improved to a comparable degree to the preoperative sensation over 6 months postoperatively. In the lateral septum cases, it reached 95% of the normal, and in medial septum cases, it reached up to 75% of the normal. In studies by Hamdi et al.[20], nipple sensation after lateral mammaplasty was markedly decreased in the first 3 months postoperatively with improvement in 6 months. They compared sensation after lateral septum pedicle to superior and inferior pedicle reduction, with results in favor of the lateral septum pedicle. This can be explained by preservation of the deep and superficial branches of lateral cutaneous nerve of 4th intercostal nerve[20].

Schlenz et al.[21] stated that decreased nipple sensation after mammaplasty is dependent on the technique of resection, the site of resection, and its relation to nerve supply. They concluded that any surgical technique that includes tissue resection behind NAC decreases the nerve supply (e.g. Lejour and Lassus techniques), whereas McKissock and Würinger techniques did not alter the sensibility of NAC[22].


  Conclusion Top


Septum-based reduction mammoplasty is safe, reliable, and non-time-consuming surgery that provides secured nipple vascularity and sensation. It can be done alone or combined with other plastic surgery procedures with no added risks, and applying this technique in further studies with more number of patients will give this technique a more satisfactory and predictable outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Derby BM, Grotting J, Redden DT. Vertical sculpted pillar reduction mammaplasty in 317 patients: technique, complications, and breast-Q outcomes. Aesth Surg J 2016; 36:417–430.  Back to cited text no. 1
    
2.
Ryssel H, Germann G, Reichenberger R. Craniomedial pedicled mammaplasty based on Würinger's horizontal septum. Aesth Plast Surg 2010; 34:494–501.  Back to cited text no. 2
    
3.
Hamdi M, Greuse M, DeMey A, Nemec E. Breast sensation after superior pedicle versus inferior pedicle mammaplasty: prospective clinical evaluation. Br J Plast Surg 1999; 54:39–42.  Back to cited text no. 3
    
4.
Greuse M, Hamdi M, DeMey A. Breast sensitivity after vertical mammaplasty. Plast Reconstr Surg 2001; 107:970–976.  Back to cited text no. 4
    
5.
Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of mammary gland. Plast Reconst Surg 1998; 101:1486–1493.  Back to cited text no. 5
    
6.
Hamdi M, Hmmond D, Nahai F, editors. Vertical scar mammaplasty. New York: Springer Verlag Berlin Heidelberg; 2004. p. 3.  Back to cited text no. 6
    
7.
Hamdi M, Patrick T, Alex V. Septum-based mammaplasty. A surgical technique based on Würinger's septum for breast reduction. Plast Reconst Surg 2009; 123:443–454.  Back to cited text no. 7
    
8.
Wüeringer E, Tschabitscher M. New aspects of the topography of the mammary gland regarding its neurovascular supply along a regular ligamentous suspension. Eur J Morphol 2003; 40:181.  Back to cited text no. 8
    
9.
Würinger E. Refinement of the central pedicle breast reduction by application of the ligamentous suspension. Plast Reconstr Surg 1999; 103:1400–1410.  Back to cited text no. 9
    
10.
Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg 1999; 104:771–781.  Back to cited text no. 10
    
11.
Lejour M. Vertical mammaplasty: early complications after 250 personal consecutive cases. Plast Reconstr Surg 1999; 104:764–770.  Back to cited text no. 11
    
12.
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture for control of areolar diameter and shape. Plast Reconstr Surg 2007; 119:804–809.  Back to cited text no. 12
    
13.
Skoog T. Plastic surgery: new methods and refinements. Stockholm: Almquist & Wiksell; 1974.  Back to cited text no. 13
    
14.
Blondeel PN, Hamdi M, Vande Sijpe KA, Van Landuyt KH, Thiessen FE, Monstrey SJ. The laterocentral glandular pedicle technique for breast reduction. Br J Plast Surg 2003; 56:348–359.  Back to cited text no. 14
    
15.
Strauch B, Elkowitz M, Baum T, Herman C. Superolateral pedicle for breast surgery: an operation for all reasons. Plast Reconstr Surg 2005; 115:1269–1279.  Back to cited text no. 15
    
16.
Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999; 104:748–763.  Back to cited text no. 16
    
17.
Stevens G, Vath SD, Stoker DA. Extreme cosmetic surgery. A retrospective study of morbidity in patients undergoing combined procedures. Aesthet Surg J 2004; 24:314–318.  Back to cited text no. 17
    
18.
Stevens WG, Gear AJ, Stoker DA, Hirsch EM, Cohen R, Spring M, et al. Outpatient reduction mammaplasty. An eleven-year experience. Aesthet Surg J 2008; 28:171–179.  Back to cited text no. 18
    
19.
Carpelan A, Kauhanen S, Mattila K, Jahkola T, Tukiainen E. Reduction mammoplasty as an outpatient procedure: a retrospective analysis of outcome and success rate. Scand J Surg 2014; 104:96–102.  Back to cited text no. 19
    
20.
Hamdi M, Blondeel P, Van de Sijpe K, Van Landuyt K, Monstrey S. Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction. Br J Plast Surg 2003; 56:360–364.  Back to cited text no. 20
    
21.
Schlenz I, Rigel S, Schmper, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty a prospective comparison of five techniques. Plast Reconstr Surg 2005; 115:743–751.  Back to cited text no. 21
    
22.
Güemes A, Pérez E, Sousa R, Gil I, Valcarreres MP, Carrera P, et al. Quality of life and alleviation of symptoms after breast reduction for macromastia in obese patients: is surgery worth it? Aesthetic Plast Surg 2016; 40:62–70.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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