Constructive Skepticism - Case In Point: Liposuction Breast Reduction
Throughout my training I was cautioned that the most dangerous times for a patient to undergo a surgical procedure were the first week in July, when new residents were beginning their training, and any week after a major conference, when surgeons were attempting the best and latest techniques. With regard to the editorial Listen Carefully, But Adopt Skeptically (Plast. Reconstr. Surg. 109: 2065, 2002), I completely agree with Dr. Puckett that there is a palpable trend in plastic surgery for speakers to sell their operations, and the pivot point for the sale often hinges on scars and their reduction. Having trained and practiced with Dr. Melvin Spira, I am well versed with his maxim of Function over Form and Form over Scar. Patients will usually tolerate whatever form we need to give them if it will improve their functional ability. A person will gladly replace a lost thumb with a toe-to-thumb transfer, even if it leads to a loss of form at the foot and a noticeable difference on the hand. Similarly, regarding Form over Scar-a woman will easily accept a longer lateral abdominoplasty scar in place of the poor form of a dog-ear. I agree with the author that many of the myriad procedures of the breast, abdomen, and face, which tout shorter or minimal scars, are often performed at the expense of better form. I must, however, disagree with the author's specific assertions on liposuction breast reduction.
The history of breast reduction is surgical. Over the past century, breast reduction has been modified and improved many times, but always within a surgical paradigm. Many of the improvements were functional, providing greater viability to the nipple-areola complex, whereas others were in form, providing projection and contour. Historically, however, these latter changes in form were based on plastic surgeons' perceptions of what the female breast should look like and our application of those perceptions to our surgical technique. No one asked reduction patients what they wanted; we only studied the optimal breast and attempted to copy that form. I contend that in the case of breast reduction, the concept of Form over Scar does not necessarily apply.
We must be honest with ourselves. The primary reason for reduction mammaplasty is, as the name suggests, reduction. The technique of liposuction currently allows us to move past the last century's surgical paradigms. It allows us to remove the breast weight that our patients complain about at a fraction of the recovery time, expense, and scar. It also exposes the operation to a tremendous number of women who would never have otherwise considered reduction. Although the author mentions that his patients do not mind the scar, they are a self-selected group of individuals who have accepted the surgical-reduction concept and sought his care. I believe that for each of these patients, there are many others who did not seek a plastic surgeon's help because they did not want the scars or could not afford the time away from home to recover from a traditional reduction. I am also amazed at how many women I see in my office who could not care less about nipple position. They just want the weight reduced. This concept surprised me at first, but when I realized that it was the plastic surgery community that decided how the reduction mammaplasty procedure was to be done, and that we were limited to a strictly surgical technique, I realized that we were doing the best we could. We should now be expanding our horizons and looking at those procedures that will benefit our patients in all ways. I believe that the liposuction breast reduction is one of those procedures.
If plastic surgeons do not carefully examine the liposuction breast reduction we may not only be underserving our patients, but we may also be writing our own epitaph in breast reduction surgery. This operation perfectly separates the functional (and insurable) portion of the procedure from the form (insurance-deniable) segment. Because breast reduction is aimed at reducing breast weight, it is only a short matter of time before insurance carriers realize that breast reductions can be performed as an outpatient procedure at a fraction of the cost and recovery time of a traditional surgical procedure. In a few years liposuction breast reduction will be the only type of reduction procedure reimbursed by insurance companies. Many other specialties are already putting their names on this procedure, and I believe that it would be a loss to plastic surgery if we lost this operation because we did not examine it carefully enough.
I have the utmost respect for Dr. Puckett. After all, he is certainly one of the names in plastic surgery that he mentions in his editorial. His wise words of caution when approaching new procedures are pearls of wisdom harvested from a rich plastic surgical career. I do hope, however, that he and others in the field look carefully at liposuction breast reduction as a potential plastic surgical tool and give it the study and consideration that it deserves.
Martin J. Moskovitz, M.D., F.A.C.S. offers breast augmentation surgery in:
