What Are the Types of Flap Techniques in Breast Reduction Surgery?

Hello.

Today, we will take a look at what kinds of flaps are actually used in breast reduction surgery and in which cases each one is used.

What is a flap?

A flap means a movable tissue segment that includes blood vessels.

Simply put, you can imagine it as a long, plank-like strip.

Inside this strip are blood vessels, and the nipple is located at the end.

The difference is that this strip is not actually rigid like a real plank; it is made of human tissue, so it is soft and flexible, meaning it can be bent or folded as needed.

When performing breast reduction surgery, it is not possible to move the sagging nipple and areola as a single unit.

That is why, while keeping the blood vessels connected to the nipple and areola, a long, strip-shaped tissue containing them is moved upward.

What factors must be considered when creating a flap?

When creating a flap, two factors must be considered.

First, the blood vessels within the flap must be able to deliver blood to the nipple reliably.

Second, the flap must be able to be rotated or folded so that the nipple at the very end of the flap can be moved to the desired position sufficiently.

In other words, it is about ‘blood flow and movement.’

However, these two factors are somewhat in conflict with each other.

First, in order for the vessels to deliver blood reliably from the flap to the nipple, it is generally better for the flap to be as short as possible. That is why making the flap small and short is considered one of the key techniques in reduction surgery.

The shorter the flap,

The more stable the internal blood flow

The less remaining tissue

These two factors make it possible to reduce the breast size.

"Then can’t you just make the flap as short as possible?"

You might ask that, but it is not that simple. Another factor must also be considered.

That is the movement mentioned earlier.

To move the nipple to the desired position, the flap needs to be of a certain length rather than too short, because sufficient length makes it easier to move. With enough length, the blood vessels inside the flap can avoid being bent sharply, and the flap itself can be moved smoothly.

In other words, you can understand that a flap should not be too short or too long.

The names of the flaps are classified by the blood vessels running toward the nipple from above, below, left, and right:

Superior flap

Inferior flap

Medial flap

Lateral flap

The inferior flap is a flap that uses blood vessels coming from below the nipple, and in the history of reduction surgery, it can be said to have been the first flap to receive attention. This is because these vessels come out through the pectoralis major muscle from the lower part of the breast, and among the vessels leading to the breast, they have the largest diameter. In addition, for the nipple, they are the only vessels in which arteries and veins run side by side.

If there is blood going in, there must also be blood going out, right?

That is why, when discussing blood flow issues, arteries and veins must always be considered together. In the past, when research on blood flow distribution was insufficient, there was a kind of fixation on the idea that arteries and veins must always be preserved as a pair.

However, in modern times, it has been learned that the main venous circulation of the nipple occurs not through this inferior vessel, but through the subcutaneous veins beneath the skin, separate from the arteries and closer to the skin.

Also, because this inferior vessel was at a major disadvantage in creating an aesthetically pleasing breast shape, it has gradually fallen out of the mainstream in breast reduction surgery.

Simply put,

Using the inferior flap means that tissue from the lower part must be left as the flap, and as a result, the heavy lower tissue remains even after surgery.

In such cases, over time, sagging in the lower part becomes more and more noticeable, so

The nipple is lifted,

The breast becomes flat,

The area below the nipple sags,

making pseudoptosis difficult to avoid.

So the improvement that emerged was the superior flap,

and it is currently one of the most widely used methods along with the medial flap.

The greatest advantage of the superior flap is its advantage in shape. Most people undergoing breast reduction surgery want the breast made smaller and removed as much as possible, but in reality, some part must still be left behind.

If you divide the breast into areas, if the sagging lower part must be removed, then naturally you would want to preserve as much of the upper volume as possible.

In this way, using the superior flap has the advantage of preserving the upper part while removing the lower part.

Also, because the tissue from the cut lower part is brought toward the center from both sides and rearranged, the result has a fuller and more three-dimensional appearance.

The decisive reason the superior flap became the standard was that scientific analysis of blood flow to the nipple confirmed that the vessels above the nipple can also supply enough blood, just like the inferior vessels.

These upper vessels do not run together with arteries and veins, so they were previously overlooked, but as it was confirmed that venous circulation of the nipple occurs mainly in a separate layer closer to the skin, both shape and stability gained theoretical justification.

However, there is also a drawback.

If the breast sags a lot and the nipple is positioned too low, using a superior flap makes the flap too long.

Therefore, the part that must be left behind becomes longer, and in breasts that are very saggy, there is inevitably a limit to how much the size can be reduced.

What is the method when the nipple has dropped very low?

The first method to attract attention was the lateral flap, because among the many nerves leading to the nipple, the most important one comes from the outer side of the breast. Therefore, it could preserve the major nerves along with the vessels, and it gained attention as a method that could maintain nipple sensation well.

However, drawbacks of this method also gradually became apparent.

Because much of the breast glandular tissue is located on the outer side, placing the flap laterally meant that the outer glandular tissue could not be reduced, which became a disadvantage.

The surgical result also made the outer side look large and sagging, making it difficult to achieve a good aesthetic outcome.

That is why the medial flap is widely used to improve severely sagging breasts.

It is favored by many surgeons in Korea and abroad because it has the advantage of allowing free excision of the lower tissue, which is the main cause of sagging, and the outer glandular tissue.

However, in some cases, for example when the nipple is positioned extremely medially, there is not enough length to move this medial flap, so in such cases there is no choice but to select a different flap instead of the medial flap.

To summarize,

For breasts with relatively less sagging: superior flap

For breasts with significant sagging: medial flap

This is the current standard.

Of course, this is not something that can be divided so mechanically; selecting the flap according to each breast shape and nipple position is important.

Therefore, the judgment and experience needed to choose the appropriate flap according to each individual breast condition can be said to be essential skills for a doctor specializing in breast reduction surgery.